A 311 for Healthcare. It’s the future.

Primary care has traditionally been an initiative led by a primary care doctor in scheduled exam rooms in a clinical office setting. They’ve got a support staff of nurses, billers, and office staff with an overhead of ~70%. It’s all powered by a business model wherein the more you use, the more you pay. Needless to say, this model is dysfunctional for both doctors and patients. There is a 22 day wait in NYC to see a primary care doctor, and 45 days in Boston. Primary care is supposed to be a front line defense for health issues. Physician workforces in the UK and Canada are composed of 75% primary care doctors and 25% specialists. Primary care has taken a sustained beating over the last few decades here in America. Of the ~580,000 practicing physicians in America treating adults, 27% are full-time primary care doctors (family practitioners, internists, and geriatricians). Primary care hasn’t scaled nor risen to today’s consumer expectations. The primary care failure has also given rise to other silos of care, like urgent care centers, retail health clinics, and direct to consumer video visits with doctors. Given their increase, it’s become quite clear that patients choose accessibility over the old-fashioned idea of a close relationship with your own primary care doctor.

Thirty-three percent of primary care doctors are aged 55 or older and 14% of them are planning on retiring in the next five years at an average age of 66. In 2014, 12% of medical school graduates entered residency programs dedicated specifically to primary care. More primary care doctors are leaving than entering. This makes sense. Primary care doctors are overworked and they get less prestige and money than specialists. Specialists make around $2.5M more over their lifetime than primary care doctors. This leaves our country in a bit of a pickle. If primary care is slowly dying, we have three options:

• Increase the number of office-based primary care doctors
  
  
  

• Increase the number of “physician extenders” like nurse practitioners and physician assistants to free up physicians to see more complicated patients
  
  
  

• Increase the efficiency of a dwindling number of primary care doctors
  
  
  

Increasing the number of PCPs is a massive cultural change in the profession. This would involve increasing pay to PCPs and making primary care a respected specialty. Although this is something we should strive for, this would take decades of change making this an unrealistic solution to our immediate problems. Increasing physician extenders is also a big, decades-long strategy. That leaves increasing the efficiency of primary care doctors, what I like to call “scaling primary care.”

There are two basic theories to scaling primary care. Both involve analyzing the processes of today’s primary care doctors. The first is best exemplified by Virginia Mason’s efforts to leverage Toyota Lean theories to help their doctors see more patients while delivering higher quality care. Designing better processes to enable one doctor to go from seeing 20 patients a day to 24 increases efficiency by 20%. While this is a positive step in the right direction, I argue this doesn’t go far enough given our massive primary care visit deficits. Multiple academic and government entities have reported something similar to what this recent study in the Annals of Family Medicine states:

“Driven by population growth and aging, the total number of office visits to primary care physicians is projected to increase from 462 million in 2008 to 565 million in 2025. After incorporating insurance expansion, the United States will require nearly 52,000 additional primary care physicians by 2025. Population growth will be the largest driver, accounting for 33,000 additional physicians, while 10,000 additional physicians will be needed to accommodate population aging. Insurance expansion will require more than 8,000 additional physicians, a 3% increase in the current workforce.”

We’re way behind the curve, which leads me to the second theory of scaling primary care— go back to the drawing board and give primary care a full rethink about what primary care is and what it should accomplish. 

And for this we need a fundamental shift from defining primary care in terms of who is providing care to what it is primary care should accomplish. 

Primary care should mean getting every patient the right care at the right time from the right entity every single time in as few time and money-consuming interactions as possible. It’s defining the problem, creating a solution, and managing the project as successfully as possible. Primary care should function more like NYC’s 311 service, using their mission as a framework:

• Provide the public with quick, easy access to all {healthcare services} and information while maintaining the highest possible level of customer service.
  
  
  

• We help {primary care doctors and specialists} improve service delivery by allowing them to focus on their core missions and manage their workload efficiently.
  
  
  

• We also provide insight into ways to improve {healthcare} through accurate, consistent measurement and analysis of service delivery.
  
  
  

311 works via a phone call or an in-app message. The problem is first fielded by generalists, via online communication, when they have the knowledge and expertise to resolve your problem. If the generalist is not the best suited to solve your problem, they are measured by how quickly they put you in touch with the right entity best equipped to solve your problem. Diagnosing, triaging, and connecting are their core competencies. However, this works best for one and done, quickly solved problems, like “fix the pothole on my street.” What about issues that need ongoing updates and communication, like treating an infection with antibiotics and ensuring its resolution upon the full course of treatment? This is where the future of primary care gets interesting. And let’s face it, most of primary care isn’t that cerebral. It’s tackling and treating issues that don’t require a specialist. It’s also understanding when to refer to specialty care. In order to scale primary care, we’ve got to maximize what primary care doctors are good at— diagnosing and setting a plan in motion. At the same time, we’ve got to limit what they’re not good at— executing on the plan they set in motion and ensuring every detail is accomplished. Doctors, generalists and specialists, they all get off on cerebral thinking. It strokes our egos and tickles the brains we honed in our many years of training. And doctors hate chasing down labs, making sure their patients are taking their medication, or ensuring their patients went to that neurologist visit. That’s the stuff that kills our egos. But that is literally the bread and butter of executing on quality primary care. You can think of today’s primary care as 2,500 patients (a typical number of patients in a doctor’s practice) that all need their medical problems project managed by one doctor from the confines of their exam rooms. And no communication is allowed in between scheduled, paid office visits. Life happens not in the presence of your doctor. People spend, on average, less than an hour with doctors every year. And 8,765 hours in the real world outside of the doctor’s office. So we need to think “outside of the exam room” and re-imagine how primary care works and what it should accomplish.

So what does the future of primary care look like?

There are four main players

‘Health 311” operators. They are the front lines of primary care and use data-driven algorithms to route the case to the health professional best suited to solve the problem.

Virtualists. They are health professionals who are 100% dedicated to virtually treating patients. They never see patients in person. They are communicating online with patients and care coordinators all day. Virtual care has markedly different workflows and processes than in-person medicine. Virtualists leverage the following to diagnose and manage conditions:

• A very accurate online checklist-driven gathering of the patient’s story
  
  
  

• Lab tests
  
  
  

• Imaging
  
  
  

• Photos
  
  
  

• Time (“let’s check in in 4 hours to see if your belly pain is better or worse”)
  
  
  

IRLists. They are traditional healthcare professionals, both generalists and specialists, based in traditional brick and mortar facilities who are leveraged when an in-person visit is necessary. They only see patients in person in an office setting. Mixing virtualist and IRList processes and workflows would make things untenable for doctors and disappointing for patients. It’s best exemplified by today’s doctor/patient email systems that have a disclaimer stating “You can expect a response from your doctor in 2 to 3 business days.” Slow service won’t fly for savvy consumers. IRLists leverage the following to diagnose and manage conditions:

• A very accurate online checklist-driven gathering of the patient’s story plus verbal questions and answers with patients
  
  
  

• Lab tests
  
  
  

• Imaging
  
  
  

• Physical exam
  
  
  

Online care coordinators. They are communicators and project managers responsible for ensuring a health plan is enacted and successful.

It is enabled by:

• An always-on online communication platform between patients and medical professionals that uses asynchronous email-like communication much, much more than synchronous phone or video calls, on the order of 95% asynchronous to 5% synchronous.
  
  
  

• Health professionals who only deliver 100% virtual or 100% in real life care. It’s one or the other.
  
  
  

• Health professionals who are either diagnosing, creating, and reassessing plans OR ensuring the plan is carried out and goals are met.
  
  
  

It is guided by a few principles.

Accessing healthcare will first begin online. Primary care will be more like a 311 for healthcare. The case will first be created online with a patient’s own detailed description of the problem. Based on the patient’s description, health 311 operators will ask a series of detailed questions to better understand the situation and rule out urgent or emergent issues. All of these questions are meaningful data points.

There will be elevation algorithms to route you to the right virtualist or IRList. The health 311 operator, augmented by algorithms, will make a data-driven decision to determine if this is a virtualist or IRList issue. Is this an issue that can be diagnosed and treated without an in-person visit? Is this an issue that needs an initial in-person visit with a generalist or specialist? If the issue can be managed with online communication, the case is elevated to the appropriate virtualist. The virtualist will already have 95% of the relevant story, eliminating the time it would have taken to collect the story. Medical diagnoses are traditionally based on the details of the story, tests, and decreasingly, the physical exam. Virtualists have the history, tests, and online communication over time as tools to diagnose and treat. Based on the story, the virtualist may send the patient to get labs or imaging to confirm their suspicions. If the “health 311 operator” determines an issue needs an in-person visit, the patient is connected to the most appropriate brick-and-mortar based generalist, specialist, or facility best suited to make the right diagnosis. NYC’s 311 system has the city’s resources mapped out and available for referrals. The Health 311 system also has the local IRList network mapped out based on availability.  

Intelligent technology routes communication to the same health professionals maintaining continuity. Consumer allegiance is primarily to the health 311 service. Algorithms route your case to virtualists and care coordinators with whom you’ve previously communicated with, maintaining virtual continuity. Continuity is vital to quality care and decision-making. However, it’s not hard and fast. When communication is in readable, text format, any health professional can read the entire thread and make decisions. Consumers are more interested in getting their problem solved by a high quality professional than maintaining continuity with one person. People can’t have favorite uber drivers they wait for. They simply use uber to get from one place to another. It’s a relationship with the utility, not the driver. While this is a significant departure from the old-fashioned doctor-patient relationship, it’s a necessity given our massive primary care shortage. Again, this isn’t the death of in-person relationships in healthcare. They’ll still be the hallmark of chronic care specialties. But over time, consumers will develop more brand loyalty with a valuable service that’s accessible, reliable, and effective.

Once a diagnosis, strategy and plan from the right virtualist or IRList is in place, the heavy clinical decisions have been made and a handoff to a virtual care coordinator is initiated to execute the plan. The plan will include goals and red flags coordinators need to watch out for. It will be detailed and accessible online by the patient and care coordinator. It’s going to look and feel similar to CareKit. This separates the strategic decision-making from the day-to-day execution, scaling the unique clinical decision-making capabilities specific to primary care doctors. This frees primary care doctors to do what they do best and provide the most value to a population. The virtual care coordinator is trained in project management and customer service. They ensure goals are reached and red flags are identified and brought to the virtualist’s attention. Did the plan involve medication and regular testing? Was there a referral to a specialist? Did the visit with the specialist happen? Has the patient been meeting their established goals in their care plan? The virtual care coordinator ensures the plan is on track.

Communication between patient and care coordinator will be 95% secure, asynchronous messaging and 5% in real time on the phone. If a red flag is identified, the virtualist will be looped into the conversation to reassess the strategy and goals. It will be extremely rare to go back into the office, unless a repeat physical exam is necessary for further management. Primary care will be less about in-person relationships and more about online problem solving. Honestly, what do we value most as physicians? Exam room conversations or effective problem solving that makes people well? The exam room relationship, while nostalgic and quaint, has proven to be ineffective and unscalable. People forget 85% of what their doctor says in the exam room, making doctor conversations 15% effective. We need healthcare communication to be 100% effective and execution of a health plan to be as near to 100% effective as possible.

Data will be shared and made public in real time. In this type of primary care scenario, the entire primary care interaction are meaningful data points that can be analyzed and used to make processes and therapies more effective. Imagine if you could view real-time trends for symptoms in a neighborhood. Or you could see that this one component of a plan resonates with patients much better than another option. You can’t change what you don’t measure. With 311 for healthcare, the entire healthcare interaction from beginning to end is analyzable. With traditional healthcare, conversations and actions are offline and oral leaving billing data as the only analyzable data. Billing data is a tiny fraction of a healthcare situation and often doesn’t reflect reality.

This is an entirely new process of healthcare delivery. 

This works for both primary care and specialty care, but let’s start with getting primary care right. When patients adopt the new behavior of going online first, we’d see a 70% reduction in in-person primary care visits. Instead of people forgetting the vast majority of what their doctor says in the exam room, we’d see nearly 100% of patients understanding their plan and strategy to get their health on track, and supported 24/7 by their team of care coordinators and virtualists. This process works, but it starts with a marketing campaign to educate patients that accessing care means going online first. There is endless precedent in this consumer behavior. Think Google, uber, OpenTable, Facebook, Airbnb, Waze, and thousands of others. Design a far more convenient service that reliably and effectively works, invite people to use it, and leapfrog the status quo. It’s that simple, right?

P.S. Over the last 4 years, this is exactly what we’ve built as Sherpaa’s platform.  We’re doing this today. Our virtualists (internists) work full time for us and do this day in and day out. They diagnose, treat, and manage 70% of all issues. They refer 30% of issues, get consults back from the specialists, and then manage those cases over time. We cover a little over 150 companies in all 50 states and their employees. On average 70% of employees within a company treat Sherpaa as their first point of contact for medical issues. It’s exciting to create.