Imagine sitting with an author of a novel that has 15 chapters. She tells you to pick her book up and read chapter 4 and then put it down. It’s such an awkward place to start, but the chapter was interesting and you want to know more. So you start peppering her with questions about the first 3 chapters. After 6 or 7 minutes, time’s up. You don’t have all day. It’s time to move on to the next author.
This is what it’s like being a doctor trying to understand the stories patients tell us about their health issues. Health issues are stories that evolve over time. They follow the classic story structure and have a beginning, middle, resolution, and, ideally, an end. An exam room visit is a small snippet in a much larger story. The best doctors are professional investigators who know the highest yield questions to ask about the earlier chapters. But the best doctors can’t predict the future. Once the “author” leaves, doctors again have to skip chapters and catch up in sometime in the future after the story has evolved for the better or worse. That is, if the author comes back.
This is the problem with 12-minute buckets of episodic care whether that care happens in the office or via video. Asking all the right questions that cover all bases in real time. Responding with accurate, thoughtful answers. And then having no easy way to share more simple and complex details as the story evolves. It’s as if the doctor-patient relationship is a 15 chapter novel where the doctor only gets to read Chapter 4 and Chapter 9.
This weekend, the WSJ reported on a recent study that analyzed the accuracy of today’s typical doctor-patient video visit:
“The services failed to ask simple, relevant questions of patients about their symptoms, leading them to repeatedly miss important diagnoses,” said Jack Resneck, a dermatologist with the University of California, San Francisco, and lead author of the study, published online in JAMA Dermatology on Sunday.
Ateev Mehrotra, an associate professor of health-care policy at Harvard Medical School who wasn’t involved with the current study, said it “identifies a number of egregious quality issues that raise significant concern.”
Since 2007, when I started the world’s first internet-driven house call practice, I’ve been an outspoken critic of the healthcare transactional visit in both physical, and most recently, virtual settings. In response to what I saw as a serious issue with quality in both physical and virtual doctor-patient transactions, I designed a process, found in Sherpaa, that solves the following issues:
- Doctors don’t always ask appropriate breadth of questions about the immediate situation
- Doctors don’t always ask the appropriate breadth of questions about the patient’s past medical history
- Patients don’t have time to thoughtfully answer questions
- Doctors don’t have time to educate and explain the value and risks of their treatment options
- Patients can’t send quick or more lengthy updates to their doctors about their evolving stories
Doctors don’t always ask appropriate breadth of questions about the immediate situation.
Roughly 90% of obtaining an accurate diagnosis stems from taking a proper, detailed history. The questions doctors ask are designed to rule potential diagnoses in or out. However, within in-person conversations, conversations can meander, both doctors and patients can get side-tracked, and it’s nearly impossible to follow a checklist to ensure you’ve covered all bases. Over the past 4 years, the Sherpaa clinical team has built roughly 250 protocols for asking the proper breadth of questions for the presenting symptoms. We have ~7,000 questions in our backend nested below a symptom, like neck pain. When a patient presents with neck pain, our doctors respond with the same 28 questions that all patients with neck pain are asked. This is the definition of checklist-driven history taking to rule out serious issues, but also give our doctors the information they need to understand which rabbit hole they should head down.
Doctors don’t always ask the appropriate breadth of questions about the patient’s past medical history.
The patient’s past medical history is only relevant if it’s up to the minute accurate. Immediately after submitting their case, as patients are already engaged and waiting for our doctors to respond, we either ask them targeted questions about their medical history or play their previously reported answers back to them to ensure it’s still accurate. We do this with a new bot we debuted a few weeks ago that’s found within our app. His name is Sherpee.
Patients don’t have time to thoughtfully answer questions.
If you’re in an exam room and a doctor is throwing question after question at you interrupting you a few seconds into your response, it’s stressful and intimidating. It’s better to get a series of questions with big free text boxes that you can answer thoughtfully without stressing or feeling that you haven’t been listened to. This is why we’ve designed Sherpaa’s question and answer process in this way. It allows patients to tell their story in their own words and on their own time and terms. It also allows them to communicate potentially embarrassing issues without having to look someone in the eyes. The quality of Sherpaa’s history-taking process is unprecedented in healthcare and we are still the only place in healthcare where the entire history of the story is written in the patient’s own words and on their own time and term.
Doctors don’t have time to educate and explain the value and risks of their treatment options.
Sherpaa’s definition of compliance is “does the patient truly understand the value of an affordable, realistic treatment plan that fits into their lives?” The rest of healthcare defines compliance as “did the patient take the medication prescribed to them?” This assumes the patient properly understands the value of the intervention. If people don’t understand the value, you can’t expect them to engage with the plan. That’s why Sherpaa built ~250 treatment protocols for our 250 most popular diagnoses. Each protocol contains a description of what the issue is with links out to the best articles or videos that best describe the issue at hand. For each medication we prescribe, we link out to Iodine to ensure the patient understands the pros and cons of the medication our doctors want to prescribe for them. And then we do something unprecedented in healthcare. When our doctors want the patient to take a medication, we send the patient a request to approve or deny the prescription. If a patient approves the medication, they choose their pharmacy, which triggers the e-prescription. If a patient denies the prescription, they give a reason like “this is too expensive” or “I’ve tried this before and it didn’t work.” The goal here is to create a realistic treatment plan the patient understands and believes in.
Patients can’t send quick or more lengthy updates to their doctors about their evolving stories.
Health issues can take turns for the better, but also for the worse. Today, exam rooms or scheduled video visit are the only avenue patients have to provide updates. This creates a barrier for good communication. Some updates are quick and simple and others are diatribes. But the smallest update can drastically change the story. Updates need to be as simple as logging into an app and communicating the issue within the case. Barriers to updates are unsafe leading to low quality outcomes.
And that’s the big issue highlighted by this new study on traditional, transactional video visits with doctors. These kinds of visits are poor quality, unsafe, siloed and irresponsible. And that fundamentally stems from the core design of the video service. It takes what’s already a terrible means of communication, the exam room, and makes it worse via video. They are designed to perpetuate the problems of the exam room visit except video visits can’t order tests to confirm diagnoses nor follow up with the patient to ensure their story is evolving positively. Today’s video transaction visits are siloed without the ability for video doctors to communicate and coordinate care with local specialists and facilities. And it is irresponsible to use physicians to treat pink eye, when we need all the primary care physicians we can get to actually do real primary care that moves the needle on our nation’s health.
Needless to say I’m very anti-video visit. Mostly because it’s a shitty way to deliver care. Transactional video visits are fundamentally flawed by their design and I hope more studies can be done to prove they are low quality and unsafe. But I’m not a complainer. I’m an observer and a doer. I identify weaknesses and inefficiencies and build something better that addresses my complaints. Hence, Sherpaa. We welcome an opportunity to work with any independent entity interested in studying Sherpaa’s process of delivering high-quality, checklist-driven care that facilitates doctor-patient communication about the issue quickly and effectively throughout the entire story from beginning to end.