The advantages of asynchronous medicine: the doctor perspective

Yesterday, I wrote about the advantages of asynchronous communication and problem solving from the perspective of the patient. But what about for doctors? Does it make their practice easier or harder? Are they better doctors or worse? What can asynchronous doctors do that their traditional counterparts cannot?

After 7 years of practicing exclusively asynchronously, our doctors believe practicing asynchronously is far safer, more efficient, and much easier than traditional exam room medicine. That’s 100% because the practice was designed as a very structured process and our tech platform was built to make each step of that process as efficient and structured as possible. When you think of traditional exam room visits as a care delivery process, you can quickly see how unstructured and messy it is.

First of all, your tools are scattered everywhere. You’ve got your EMR in one corner and everyone knows how inefficient and messy they are (61 clicks to order Tylenol!?), your exam tools in a drawer, your nurse somewhere in the office, but you can’t find her, etc..

And, second, because time slots are the main tool, it becomes a very linear process where doctors move in 15 minute chunks. When processes are linear, bottlenecks are inevitable, hence the reason why patients sit in an exam room for 45 minutes as the doc is tied up with a complicated patient a few time slots before you.

But think of asynchronous medicine more like your email. You get a steady stream of email all day and some require more time/effort than others but other emails simply require a very quick, almost mindless response. Very few issues are time sensitive so you can triage your efforts appropriately. This kind of communication turns medicine from a linear, spinning your wheels, bottleneck-prone process into a hyper-efficient branched process where there’s constant, efficient communication and problem-solving with patients.

Of course, you couldn’t do this on your phone with unstructured SMS or iMessages. Most communications can’t just be free text. That’s not efficient. A doctor couldn’t do this with gmail either as some messages need to be structured, not just free text emails. Doctors need structured sets of pre-built questions, structured pre-built care protocols, structured refill requests and e-prescriptions, structured referrals that include specialist or facility profiles and contact information, structured test orders and results, etc.. Because of these efficiency opportunities, you need your own specialized tech platform designed to help you keep track of all the activity happening in your entire patient panel. You need to know when messages have been read, when the patient hasn’t yet answered your questions, when they have a new question about the medication you prescribed, etc. You don't want vital information and communication just sitting out there, unaccounted for, and not officially documented. The tech platform needs to be 100% focused on helping doctors keep track of every single moving part in their population of patients they’re managing not just today, but for months on end as reminders to check-in with patients from a visit two months ago pops into their to-do’s for the day.

Once you have a dedicated, specialized platform, then you start analyzing what a doctor does with their time, minute by minute, every single day. So let’s think about this from a traditional perspective and compare it to an asynchronous doctor.

Asynchronous doctors are 40% more efficient because they don’t have to document in an EMR. Plenty of research suggests that ~40% of a doctor’s day is spent turning an oral conversation into EMR data meant to maximize their reimbursement. When hyper-structured asynchronous messaging is 95% of the communication you have with patients, that messaging is the documentation. This single fact makes asynchronous doctors ~40% more efficient than their doctor scribe friends.

To put some meat around this concept of asynchronous efficiency, a traditional exam room PCP has 1,500 to 1,800 patients in their panel. Asynchronous practices have ~3,000 patients in their panel. Forty percent of that efficiency is because asynchronous doctors do not need to translate an oral conversation to EMR documentation.

Asynchronous doctors can standardize and automate most of the question and answer history-taking.

Then, they must listen to responses with enough patience to let patients feel heard. The vast majority of a doctor’s time is spent seeing the same common conditions and asking the same questions over and over. This is a huge time suck for traditional doctors because oral conversations aren’t structured and patients need enough time to process the question and their answers. With asynchronous medicine, you can build structured question sets around each chief complaint that can loaded by searching for the question set and editing, adding, or deleting any question in the question set. These questions can also be optimized for how the questions are worded and complicated concepts that can be explained to patients by linking to videos or other strong online health content. This takes the 5-10 minute oral conversation between you and a patient into a hyper-efficient read where the patient can explain herself in her own words and not feel pressured for time, nor experience any interruptions. And based on the answers from the first round of questions, you can then send a few more questions to dive into more details. This asynchronous, standardized history taking using pre-built protocols shaves ~40% of the time traditional doctors spend on taking histories via oral exam room conversations.

Asynchronous doctors can standardize and automate most of communicating the plan to patients.

Again, all doctors spend the majority of their time treating common health conditions. This means they have to explain the same treatment plan over and over. And when they are explaining things patients forget ~85% of what doctors say in oral conversations. But with asynchronous medicine, you can create treatment protocols for the most common conditions and load them with one click, edit them appropriately, and send them off to the patient to read at their leisure, click on links to the best online content to help them best understand complicated issues, re-read whenever they want, or ask more questions based on what you sent them. This shaves ~40% of the time traditional doctors spend explaining the plan to patients. And instead of patients remembering only 15% of what they hear and scrambling to take notes, they can theoretically understand 100% of the plan and review the entire conversation at any time.

Asynchronous doctors can use time as a tool to diagnose.

All doctors use the information they gather to determine diagnoses. They use history taking, physical exams, tests, experimentation, and observation. Most every condition has a natural, expected course. Sometimes you see something early in the course and say to yourself, in a few days, this may evolve into something worse. Or sometimes you see something and say, you know what, let's just reconnect in 4 hours or tomorrow and see how you're feeling and we'll reassess and then determine how we'll treat this. Asynchronous doctors can use time/observation/reconnecting to their advantage to practice very conservative medicine. You don't have to rush to prescribe antibiotics because you know you can't follow up easily with this person and you want to protect yourself. When the patient has to proactively make another appointment if their condition worsens or evolves into something else, doctors tend to bring out the big guns rather than the more conservative, let's just wait and see.

Asynchronous doctors can prescribe and refill medications (one example of a quick, simple transaction) extremely easily in a structured way.

When patients can simply request a refill, take a photo of the pill bottle, and doctors can e-prescribe based on the patient’s request and answers to any questions you have, this eliminates the phone tag and inefficiencies patients hate when trying to carry out what should be a very simple task.

Asynchronous doctors don’t have to be expected to know everything in real-time.

Maybe a patient has a perplexing story? Maybe you haven’t seen this condition in a few years? Maybe you heard there’s a new treatment for an uncommon condition you’re observing in an exam room? When you’re seeing patients in real time, it’s hard to ask a colleague for a curbside. And researching to brush up on your knowledge will cause a bottleneck affecting all patients for the rest of the day. But because you don’t have to respond in real-time to patients in asynchronous medicine, you can ask another asynchronous doctor to read a perplexing story in a thread and talk it through with you offering patients a consensus rather than just your own opinion. Or you can easily visit Up to Date and read the latest treatment strategy for an uncommon condition and then respond to the patient after you’ve educated yourself. You no longer have to wing it as pressure to prevent bottlenecks builds up. You can respond knowledgeably and thoughtfully.

Asynchronous doctors can easily get help from specialists and other experts.

Sometimes you recognize a situation where you know the patient doesn’t need an in-person visit to a specialist, but you just need the specialist to answer one or two questions about how to diagnose or manage a condition. With traditional medicine, you’ve got to refer and add two more visits to the patient’s experience (today’s visit, the specialist’s visit, and a follow-up visit with the patient to discuss the specialist’s recommendations). With asynchronous medicine, you can curbside a specialist, ask them targeted questions, invite them to read the thread, and respond to you with their answers and recommendations. Of course, the patient can also see the response giving patients their legal right to all of their information.

Asynchronous doctors can do what they do best (diagnose and treat) and get support from administrative staff and health coaches responsible for working as needed with patients to execute the doctor’s plan and solve your problems.

The best way to put this is the patient is the CEO of their health, doctors set the plan in partnership with the patient, and coaches are a patient’s everyday support to solve health problems. Coaches perform tasks like helping doctors find the most appropriate specialist or facility to refer a patient to or helping patients find the least expensive way to procure an expensive medication or interfacing with your insurance company on your behalf. Doctors can offload tasks via the specialized tech platform to ensure the task is carried out by their support staff. And because coaches and care navigators are also communicating with patients in the same thread, doctors can easily see how the situation is advancing toward resolution.

Asynchronous doctors have a ridiculously easy way to communicate with patients at all times.

Being able to remain connected to patients and communicate with them at any point in time is, by far, the safest way to practice. An inaccessible doctor and a disconnected patient is a recipe for disaster, especially when a condition takes a turn for the worse. In traditional medicine, once a patient leaves the office, there’s often not an easy way for you to reach out to say your labs are back or “I was just unsure of something from the conversation today and it’s been bothering me” and then ask the patient another question. If the issue is not time-sensitive, you can simply send the message to the patient and wait for a response. But if it is time-sensitive or more serious, you can always step up asynchronous medicine to synchronous and simply give the patient a call. It’s safe and it’s the right thing to do.

Asynchronous doctors have an easy way to get a quick update from a patient.

Just as not every problem at work needs an in-person meeting, not every medical situation needs an office visit, especially for following the progress of a condition. There is no easy way for patients to send a photo or data (like from their home blood pressure monitor) to their traditional office visit doctor. But often that’s all a doctor needs to follow progress. With asynchronous medicine, a patient can log in, snap a photo of their skin or take a screenshot of their blood pressure data (or ideally, even connect their device to their profile their doctor can access), and fire it off to their doctor in 5 clicks and the doctor gets immediately notified theirs new activity in one of their patient’s Episode of Care. Enabling this capability is just the right thing to do when practicing modern medicine. Most issues in the everyday practice of primary care are common, routine, and not extremely emotional and serious. For those very occasional emotional and serious situations, in-person visits are an absolute must.

Asynchronous doctors can provide a surprisingly high level of customer service.

They need to keep track of when they should send a check-in to a patient to see how they’re doing. This is not only best practice, it’s something most traditional doctors aren’t incentivized to do (open up a can of worms without getting paid for office visits). So when an asynchronous doctor sends a message saying “Hi Jay. Just checking in. Feeling better.” It’s a really good feel-good surprise and is a wonderful expression of empathy. People want to feel cared for and they want to know their doctor is thinking of them.

Asynchronous doctors can have a very flexible lifestyle.

An asynchronous medical platform enables them to work from anywhere. They get access to their entire patient panel whether they’re at home, at the office, at their summer home in Maine, or visiting her husband in Vienna as he’s been temporarily transferred there for the next year. They get flexibility. They get to be able to work in shifts and know that, when they’re off, their colleagues in their asynchronous group are covering their patients for them ensuring their patients’ care doesn’t stop just because they took vacation.

Synchronous processes, no matter where they occur, are subject to the same inefficiencies found in office visits. None of these efficiencies mentioned above are found in video visits. There are the same scheduling and logistical problems and the same oral conversations and the need to document them that you find in exam room visits. Of course, video visits introduce a technological challenge that doesn't exist when you can just pick up a phone. And video visits are an unwanted behavior. TelaDoc has stated that out of the meager 1.1 million visits they do per year (mind you, this is the same volume that all the urgent care centers in America do in 3 days of visits), users choose phone over video 90% of the time. The only value gained with video visits are to the patient as they skip traveling to the exam room. And finally, mixing synchronous and asynchronous care delivery processes does not work. This is something I learned while building Hello Health in 2008. If a traditional office visit synchronous doctor wants to enable asynchronous processes in their practice, this will likely fail. When doctors are busy with office visits and patients can also email them, emails are likely relegated to the end of the day or the weekend. And if patients can email or text their doctor, this is an interruption to the patient in the exam room and these communications are competing with their attention to the patient and their EMR. The doctor will likely answer these communications “when they can” which is often the end of the day or between patients when the doctor gets some down time, further contributing to traditional bottlenecks. That’s why today’s doctor-patient email portals often set expectations for patients with messaging like “You can expect a response within 3 to 4 business days” which immediately underwhelms patients who are used to having their Lyft arrive in 2 minutes. And when texts and emails are not part of the EMR (which you often see in concierge or direct primary care practices), there is highly relevant, legal information siloed in your texts and emails that is not part of the official EMR. This means a doctor can either practice asynchronous medicine and in a very streamlined way and offer speedy service to patients...or practice synchronous, traditional medicine...but they can’t practice both well.