Using technology to completely rethink the patient encounter

It’s time that we rethink the doctor’s office encounter.  It’s inefficient for doctor and patient, and doesn’t optimize care for those that need it most.  Everyone is treated the same, even though not every illness or medical need has the same urgency.

To get to see a doctor I have to make an appointment days or even weeks in advance.  I have to drive over to the complex, find parking or risk a parking ticket, go into a waiting room and wait until the nurse calls me while being exposed to ‘who knows what’ kind of germ, viruses and bacteria from other sick patients.  I then go into a patient encounter room where a nurse takes my temperature and my blood pressure.  Then I wait some more.  If everything goes well, the wait inside the doctor’s office averages about 20 minutes.  The doctor comes into the office, asks a few questions, looks at the chart, looks at the information the nurse documented and decides what should be done.  From the moment I left my house until I’m back at home, it could be as little as an hour, but averages about 2 hours.

Let’s look at how this plays out for a chronic condition such as high blood pressure.  The doctor issues prescriptions for 6 months at a time.  The doctor is monitoring the BP to make sure that the patient hasn’t developed tolerances and everything is remains under control.  Every six months, the patient must return to have their BP read, then an new prescription is issue.  Every six months the patient must put their life on hold while they return to the doctor’s office to another prescription, even if everything is working fine.

I propose using technology to completely rethink the patient encounter.  Instead of using technology to augment the ‘time inefficient’ traditional appointment model, let’s break down the entire process and figure out how to replace it with a more efficient model that saves time for the patient and the doctor while providing the best patient care possible.

I envision a system where the patient at their computer calls the doctors office on a video call.  The patient punches in their account number.  The computer on the doctor’s end automatically recognizes the patient’s medical record number, goes to the medical records data base, and provides the patients medical record to the triage nurse.  (This is standard call center technology done currently when you call customer service organizations where they ask you to enter your customer number.)  The triage nurse identifies the immediacy of the patient need and schedules them accordingly.   If the patient needs are critical, the patient is directed to the nearest ER.  If the patient needs a specialist, they are referred to the specialist immediately.  The electronic order for the referral is done immediately and the patient’s next call is to the specialists office.  Other’s are scheduled according to needs and available openings.

Think about how the BP encounter would work, using technology.  The doctor’s office is called.  The patient enters their patient ID number and a message is left that the patient wants to renew a particular prescription.  The doctor’s office, upon getting the message, has the doctor review the video of the call to verify that everything looks good and there are no signs of obvious distress.  The doctor issues a conditional prescription to the pharmacy.  During the course of the day the patient stops at the local pharmacy and has their BP taken at the local machine.  The patient hands the printed read out to the pharmacist who checks it against the conditions of the prescription.  If everything matches, the medication is handed out.  If there is a discrepancy, the patient is referred back to the doctor for a visit.   The entire process takes the patient only 15 minutes and very little deviation from daily life.  It can be handled by the doctor is less than a minute.   No medical transcription of the event is necessary because the entire encounter between the doctor and patient is recorded and becomes a part of the electronic health record.

To be fair, pharmacies will call doctor’s offices for new scripts to renew them.  However, at some point, the patient is forced into the doctor’s office.  That is the visit that this method will be ideal to replace.  For those patients who feel more comfortable with the traditional doctor’s office visit or they have more serious issues, they can continue with the same method of visiting the doctor’s office.   However, there is no reason that we should be using technology to emulate old encounters instead of rethinking and streamlining the entire thing so that everybody wins.

Gary Patterson is the founder and CEO of Pearce, Patterson and Associates, Inc.

Submit a guest post and be heard on social media’s leading physician voice.

email

Comments are moderated before they are published. Please read the comment policy.

  • JustADoc

    1) no current system in place to pay for this idea
    2)occassionally we actually do pick up something when listening to your heart and lungs
    3) oftentimes other things are caught up at otherwise routine f/u appts(vaccinations, colonoscopy remainders, schedule MMG, PAPs, etc.

    All that aside, could be done sometimes IF it was paid for but would still need to be seen at least once a year and would not be a viable option for a large percentage of my daily visits.

  • JustADoc

    1) no current system in place to pay for this idea
    2)occassionally we actually do pick up something when listening to your heart and lungs
    3) oftentimes other things are caught up at otherwise routine f/u appts(vaccinations, colonoscopy remainders, schedule MMG, PAPs, etc.

    All that aside, could be done sometimes IF it was paid for but would still need to be seen at least once a year and would not be a viable option for a large percentage of my daily visits.

    • Sack2011

       Yes, but it COULD work for all the other 10+ scheduled visits throughout that year to keep costs down? That’s what we should be looking at to make things happen (the possibilities of it working) for organizations to fund this type of an idea in the future… just as new businesses happen with venture capitalists! The U.S. has to pay for health care already and therefore someone else (not to exclude ourselves) should pay for a working system. Quite possibly, physicians could also work based on the quality of care versus its quantity by minimizing those patients that only want the “in and out” visit? Bottom line: Choice.

    • http://twitter.com/barenakedfeet Bare Naked Feet

      Steve Ponder is a pediatric endocrinologist in Texas. He’s been offering this model of care for his type 1 peds patients since 2007 and getting paid by 2 of the major health plans for remote encounters as if they were face to face. He has a pre-existing relationship (face to face) and at least one face to face visit per year either in his office or in one of his satellite clinics. http://www.texastechphysicians.com/permian/docprofile.aspx?id=601 I helped him set this up in a previous life when I ran a health care technology company. Patients love it and of course the one’s who don’t like the idea just see him in his office.

  • Fred Dempster

    Majority of the technology is or can be done with better collaboration, nothing will replace the face-to-face process with the Doctor as needed. The Doctor’s tablet can summarize what is happening, and those friendly reminders on electives we are postponing.

  • Fred Dempster

    Majority of the technology is or can be done with better collaboration, nothing will replace the face-to-face process with the Doctor as needed. The Doctor’s tablet can summarize what is happening, and those friendly reminders on electives we are postponing.

  • Emily Gibson

    Some of us are already providing this type of care in settings where the physician is not dependent on being paid per visit, but rather is salaried to keep a patient panel as healthy as possible. It is possible for a patient to have a home weight scale, glucometer, blood pressure cuff, peak flow meter, oximeter, lipid panel monitor that automatically transmits information to the patient’s electronic medical record for review by the clinician. Much face to face care can take place via video monitoring as currently happens in remote settings where a clinic visit is not feasible, including mental health evaluation, heart and lung exams, skin and wound exams, etc.

    Nothing can replace the touch of the doctor’s hand on a tender abdomen, or the repair of a laceration or a fracture, but a great deal of today’s medical care can be accomplished in innovative, less burdensome and more cost-efficient ways–something health care reform will demand.

  • Emily Gibson

    Some of us are already providing this type of care in settings where the physician is not dependent on being paid per visit, but rather is salaried to keep a patient panel as healthy as possible. It is possible for a patient to have a home weight scale, glucometer, blood pressure cuff, peak flow meter, oximeter, lipid panel monitor that automatically transmits information to the patient’s electronic medical record for review by the clinician. Much face to face care can take place via video monitoring as currently happens in remote settings where a clinic visit is not feasible, including mental health evaluation, heart and lung exams, skin and wound exams, etc.

    Nothing can replace the touch of the doctor’s hand on a tender abdomen, or the repair of a laceration or a fracture, but a great deal of today’s medical care can be accomplished in innovative, less burdensome and more cost-efficient ways–something health care reform will demand.

  • Anonymous

    Has everyone forgotten the therapeutic touch? The Art of Medicine? Where is the Care in Healthcare? Dammit, Jim. I’m a doctor, not an Info Tech.

  • doc99

    Has everyone forgotten the therapeutic touch? The Art of Medicine? Where is the Care in Healthcare? Dammit, Jim. I’m a doctor, not an Info Tech.

  • Margalit Gur-Arie

    I don’t understand why you have to measure BP at the pharmacy and why you need to print something on paper after all this techie tour de force.
    What exactly is it that the doctor will be reviewing in the triage video? Could he tell, say, if your ankles where twice the size they usually are, or something like that?

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I don’t understand why you have to measure BP at the pharmacy and why you need to print something on paper after all this techie tour de force.
    What exactly is it that the doctor will be reviewing in the triage video? Could he tell, say, if your ankles where twice the size they usually are, or something like that?

  • http://www.facebook.com/profile.php?id=762893788 Dave Miller

    Gary, first off (at the risk of sounding snarky) you should use technology to proof-read your blog posts before you send them to the world.

    Taking the example you offered, managing blood pressure, you plan might work IF blood pressure were an isolated factor that didn’t affect other parts of the body. As it is, no fewer than four (4) sets of organs are directly involved in maintaining blood pressure: the heart and vessels (peripheral vascular tone), the autonomic nervous system (vagal tone and its effects on heart rate and stroke volume, etc), the lungs (key site for production of angiotenson, pulmonary-caval pumping, etc) and the kidneys (proper maintenance of sodium and other salts). This doesn’t even take into account pathology like atherosclerotic plaques and such, which involve the liver and other organs. Medically managing this interrelation of systems is an incredibly complex dance that involves a lot more than just knowing what your blood pressure is on any given day. And this is assuming things are going well.

    If things do poorly, the effects of high blood pressure reek havoc on every organ and organ system in the body. It damages the heart and vessels, the lungs, the kidneys, the brain, the muscles, the bones, and on and on. There is absolutely no way this can be managed effectively without carefully surveillance by a knowledgeable physician.

    Indeed, this is why physicians spend four years in medical school followed by 3+ years in residency. Medicine isn’t something you can do as a hobby or on a whim. Suggestions like this ignore the complexities inherent in modern medicine, especially as the general population gets older and their medical issues more multi-factorial.

  • http://www.facebook.com/profile.php?id=762893788 Dave Miller

    Gary, first off (at the risk of sounding snarky) you should use technology to proof-read your blog posts before you send them to the world.

    Taking the example you offered, managing blood pressure, you plan might work IF blood pressure were an isolated factor that didn’t affect other parts of the body. As it is, no fewer than four (4) sets of organs are directly involved in maintaining blood pressure: the heart and vessels (peripheral vascular tone), the autonomic nervous system (vagal tone and its effects on heart rate and stroke volume, etc), the lungs (key site for production of angiotenson, pulmonary-caval pumping, etc) and the kidneys (proper maintenance of sodium and other salts). This doesn’t even take into account pathology like atherosclerotic plaques and such, which involve the liver and other organs. Medically managing this interrelation of systems is an incredibly complex dance that involves a lot more than just knowing what your blood pressure is on any given day. And this is assuming things are going well.

    If things do poorly, the effects of high blood pressure reek havoc on every organ and organ system in the body. It damages the heart and vessels, the lungs, the kidneys, the brain, the muscles, the bones, and on and on. There is absolutely no way this can be managed effectively without carefully surveillance by a knowledgeable physician.

    Indeed, this is why physicians spend four years in medical school followed by 3+ years in residency. Medicine isn’t something you can do as a hobby or on a whim. Suggestions like this ignore the complexities inherent in modern medicine, especially as the general population gets older and their medical issues more multi-factorial.

    • Sack2011

      Agreed. However, to some extent physicians need to address each patient as an individual with regard to their actual symptoms “day of” the appointment rather than addressing only the patient’s medical record. Clearly we understand that diagnosis is more than sending in a prescription via telephone yet we should also understand that quite possibly what Gary is speaking of is relating to only ‘certain’ audiences–like those younger men who do not like to even attempt the doctor’s office? Or even those like myself who feel as if being treated as primarily a “chart number” at the office and footing a bill for a few hundred dollars later would really rather stay home while sick and just phone it in–because the physician-patient relationship never changes. Not to say I discredit the amount of intelligence and work that is put forth into an M.D. status, but rather also don’t want to discredit the amount of technology available to have a more cost-efficient health care system?

  • Ernesto Gutierrez

    I think this is an interesting idea.  But I think that technology should not be guiding the nature of patient-physician relationships, but rather the physician should asking how to best use the tools best available to them to manage disease. (Unfortunately it is third party payer who, because of their imagined medical degrees, are dictating how disease should be managed)
     I agree with most of the commentators that the treatment of hypertension should not be a video conference call.  I am not against efficiency, but clearly anyone who has practiced medicine will realize that medicine is inherently inefficient.  Rarely do patients present to me like the board exams, where the H&P is clear, cut, and dry.  Chief complaints do not roll off the patient’s tongues like honey, nor follow the 8 descriptors to meet billing criteria.  I could go on, but it all boils down to the fact that patients are human.  I don’t think that replacing that one on one physical live interview with a conference call is good for most things. 
    Reducing patient wait time is a different story, and can be acheived.

  • Ernesto Gutierrez

    I think this is an interesting idea.  But I think that technology should not be guiding the nature of patient-physician relationships, but rather the physician should asking how to best use the tools best available to them to manage disease. (Unfortunately it is third party payer who, because of their imagined medical degrees, are dictating how disease should be managed)
     I agree with most of the commentators that the treatment of hypertension should not be a video conference call.  I am not against efficiency, but clearly anyone who has practiced medicine will realize that medicine is inherently inefficient.  Rarely do patients present to me like the board exams, where the H&P is clear, cut, and dry.  Chief complaints do not roll off the patient’s tongues like honey, nor follow the 8 descriptors to meet billing criteria.  I could go on, but it all boils down to the fact that patients are human.  I don’t think that replacing that one on one physical live interview with a conference call is good for most things. 
    Reducing patient wait time is a different story, and can be acheived.

  • Anonymous

    While your vision to improve efficiency is good conceptually, your example of BP exposes one of the major problem areas of healthcare: measurement systems and our understanding of variation.  It is well known that BP can vary by as much as 35 mm Hg from one measurement to the next (separated by only minutes), and that it is affected by *many* factors.  Taking a single measurement every six months is a prescription for bad decisions and bad healthcare.

    Statistical Process Control (SPC) is the method of choice for analyzing and helping to interpret data that vary over time.  It allows making the critical distinction between what is known as Common Cause variation (random, i.e., always present as part of the *current* process) and Special Cause variation (an effect, i.e., a real change).  That distinction is critical because the proper action in response to one or the other differs dramatically.  If the distinction is not made, most decisions are wrong and the subsequent action taken counter-productive.

  • waynergf

    While your vision to improve efficiency is good conceptually, your example of BP exposes one of the major problem areas of healthcare: measurement systems and our understanding of variation.  It is well known that BP can vary by as much as 35 mm Hg from one measurement to the next (separated by only minutes), and that it is affected by *many* factors.  Taking a single measurement every six months is a prescription for bad decisions and bad healthcare.

    Statistical Process Control (SPC) is the method of choice for analyzing and helping to interpret data that vary over time.  It allows making the critical distinction between what is known as Common Cause variation (random, i.e., always present as part of the *current* process) and Special Cause variation (an effect, i.e., a real change).  That distinction is critical because the proper action in response to one or the other differs dramatically.  If the distinction is not made, most decisions are wrong and the subsequent action taken counter-productive.

  • Anonymous

    It is one thing to consider the evolution of new technologies for patient care, but what about managing the implementation of that technology with office staff (clerks, nurses, admin)? As someone who has worked in change management in hospitals and private practices, this is often our greatest hurdle. I have even encountered saboteurs – staff who make the technology not work in fear the technology may replace them.

    It may be one thing to get buy-in from doctors, but what about those working for the doctors?

    I’ve had a lot of success applying ADKAR principles in managing our software implementations. Has anyone else had success with this or other approaches?

  • vlmst12

    It is one thing to consider the evolution of new technologies for patient care, but what about managing the implementation of that technology with office staff (clerks, nurses, admin)? As someone who has worked in change management in hospitals and private practices, this is often our greatest hurdle. I have even encountered saboteurs – staff who make the technology not work in fear the technology may replace them.

    It may be one thing to get buy-in from doctors, but what about those working for the doctors?

    I’ve had a lot of success applying ADKAR principles in managing our software implementations. Has anyone else had success with this or other approaches?

  • http://pulse.yahoo.com/_5OUJ3J22ICZ6NTZUQGWOJDLFOQ sams

       While I see where you are coming from, in my opinion, this idea does not increase the efficiency of the healthcare process. This type of tech does not eliminate work, it simply shifts it to other people. Instead of spending 20 minutes meeting with a patient, the doctor will likely spend almost the same amount of time reviewing the video and filling out instructions electronically, while losing the potential to identify physical problems in person. 
        Any time that is saved on the doctor’s end will simply be transferred either to the patient or the pharmacist. Rather than having the doctor take the blood pressure, the patient or pharmacist will have to do it at the pharmacy. More authority is then given to the pharmacist to determine whether or not the patient should be provided with the medicine (not that I don’t trust pharmacists, but there is a reason I pay a doctor to make these decisions). 
       What is even more likely is that the patient will end up being bogged down in the bureaucracy/inefficiency that is inherent to the “call center” framework. The way you outline this process is likely the same way phone companies originally outlined their plans for organizing customer service call centers. In theory, it sounds like an efficient concept, but in practice it tends to be worse than physical encounters. A patient would first have to call the general number for the hospital or healthcare group call center, they would then be faced with a series of automated messages to figure out the reason for their call, the patient would then most likely be transferred to a general service agent who can then transfer them to the appropriate department. Assuming these lines are even somewhat as busy as actual healthcare centers, the patient would then have to wait on hold just to get in touch with a nurse who could then transfer them to a doctor. The process would take forever and be just as inefficient and frustrating as visiting a hospital (where at least you get to actually see a doctor). This doesn’t even take into account the inability of a large number of citizens to efficiently/effectively utilize modern technology, especially those older citizens who are the largest healthcare consumers.
        The way I see it, technology such as this is most useful as a way of reaching individuals who do not have easy access to healthcare centers (i.e. rural areas, handicapped individuals, etc). The potential to expand the reach of modern healthcare services is great, but the ability to increase efficiency in the standard doctor-patient model is limited.
        

  • http://pulse.yahoo.com/_5OUJ3J22ICZ6NTZUQGWOJDLFOQ sams

       While I see where you are coming from, in my opinion, this idea does not increase the efficiency of the healthcare process. This type of tech does not eliminate work, it simply shifts it to other people. Instead of spending 20 minutes meeting with a patient, the doctor will likely spend almost the same amount of time reviewing the video and filling out instructions electronically, while losing the potential to identify physical problems in person. 
        Any time that is saved on the doctor’s end will simply be transferred either to the patient or the pharmacist. Rather than having the doctor take the blood pressure, the patient or pharmacist will have to do it at the pharmacy. More authority is then given to the pharmacist to determine whether or not the patient should be provided with the medicine (not that I don’t trust pharmacists, but there is a reason I pay a doctor to make these decisions). 
       What is even more likely is that the patient will end up being bogged down in the bureaucracy/inefficiency that is inherent to the “call center” framework. The way you outline this process is likely the same way phone companies originally outlined their plans for organizing customer service call centers. In theory, it sounds like an efficient concept, but in practice it tends to be worse than physical encounters. A patient would first have to call the general number for the hospital or healthcare group call center, they would then be faced with a series of automated messages to figure out the reason for their call, the patient would then most likely be transferred to a general service agent who can then transfer them to the appropriate department. Assuming these lines are even somewhat as busy as actual healthcare centers, the patient would then have to wait on hold just to get in touch with a nurse who could then transfer them to a doctor. The process would take forever and be just as inefficient and frustrating as visiting a hospital (where at least you get to actually see a doctor). This doesn’t even take into account the inability of a large number of citizens to efficiently/effectively utilize modern technology, especially those older citizens who are the largest healthcare consumers.
        The way I see it, technology such as this is most useful as a way of reaching individuals who do not have easy access to healthcare centers (i.e. rural areas, handicapped individuals, etc). The potential to expand the reach of modern healthcare services is great, but the ability to increase efficiency in the standard doctor-patient model is limited.
        

  • http://twitter.com/drvijay82 Dr Vijay Kumar

    There is a certain element of placebo-driven healing that takes place during the complete patient-doctor encounter. I dont have empirical research to back me up, but we run a risk of finding out the wrong way.

  • http://twitter.com/drvijay82 Dr Vijay Kumar

    There is a certain element of placebo-driven healing that takes place during the complete patient-doctor encounter. I dont have empirical research to back me up, but we run a risk of finding out the wrong way.

  • Robert A. Bernardini

    I’m not a physician. But I’d like to enter the conversation.

    I’m a patient who has, blessedly, only occasional medical problems in large part because I have a great physician whom I trust and discuss things with and feel a partner in my care. I am also a payer of medical services. I may often pay incompletely and indirectly, but in the end I pay for all services, both mine and thousands who cannot pay for themselves.

    I do not wish to be separated from the humanity, intuition and skill my doctor gives me, however I want my doctor to provide services with as much forethought as any coffee shop chain executive. Mixed metaphors? No.

    This is the ‘re-think’ I heard Gary saying.  Yes, Dave, it my BP does affect my entire body, but to get to my body can we understand that 7+ years of education and professional pride may be standing in the way? 

    Let the same technology that sends my ATM PIN to a bank data base, send my BP reading, however the calibration was set (or wasn’t) at my pharmacy (or even coffee shop for that matter) as a single data point of my being. I would then hope that your professional decision tree would move forward as you assay/triage my condition to a point where you may decide that only a person-to-person meeting will allow you to diagnose my condition correctly. I would come in and wait for that.

    In the meanwhile, I could point my webcam to my ankle to let you see any swelling, and if I’m smart enough to do that, maybe I could answer additional questions regarding anything you see or don’t see.  Hey! Ask me a question… about my own body.

    If you are comfortable collecting professional fee electronically, allow technology to make my end of the partnership a little easier for both of us.

  • Robert A. Bernardini

    I’m not a physician. But I’d like to enter the conversation.

    I’m a patient who has, blessedly, only occasional medical problems in large part because I have a great physician whom I trust and discuss things with and feel a partner in my care. I am also a payer of medical services. I may often pay incompletely and indirectly, but in the end I pay for all services, both mine and thousands who cannot pay for themselves.

    I do not wish to be separated from the humanity, intuition and skill my doctor gives me, however I want my doctor to provide services with as much forethought as any coffee shop chain executive. Mixed metaphors? No.

    This is the ‘re-think’ I heard Gary saying.  Yes, Dave, it my BP does affect my entire body, but to get to my body can we understand that 7+ years of education and professional pride may be standing in the way? 

    Let the same technology that sends my ATM PIN to a bank data base, send my BP reading, however the calibration was set (or wasn’t) at my pharmacy (or even coffee shop for that matter) as a single data point of my being. I would then hope that your professional decision tree would move forward as you assay/triage my condition to a point where you may decide that only a person-to-person meeting will allow you to diagnose my condition correctly. I would come in and wait for that.

    In the meanwhile, I could point my webcam to my ankle to let you see any swelling, and if I’m smart enough to do that, maybe I could answer additional questions regarding anything you see or don’t see.  Hey! Ask me a question… about my own body.

    If you are comfortable collecting professional fee electronically, allow technology to make my end of the partnership a little easier for both of us.

  • Anonymous

    This is why non physicians need to stay off medicine.  Technology is here to enhance our encounters with patients and provide faster and more accurate diagnosis.  It is an adjunct to our skills and our RELATIONSHIP with our patient.  Technology is NOT here to modify how we relate to our patients nor to redifine how medicine is practiced.  There is something called the ART of medicine that can not be replaced by technology.
        Docs, we need to get administrators and science techs away from dictating how medicine is practiced.  After all, we treat PEOPLE, not numbers or cases.

  • BoricuaEnArizona

    This is why non physicians need to stay off medicine.  Technology is here to enhance our encounters with patients and provide faster and more accurate diagnosis.  It is an adjunct to our skills and our RELATIONSHIP with our patient.  Technology is NOT here to modify how we relate to our patients nor to redifine how medicine is practiced.  There is something called the ART of medicine that can not be replaced by technology.
        Docs, we need to get administrators and science techs away from dictating how medicine is practiced.  After all, we treat PEOPLE, not numbers or cases.

  • Anonymous

    Agreed. However, to some extent physicians need to address each patient as an individual with regard to their actual symptoms “day of” the appointment rather than addressing only the patient’s medical record. Clearly we understand that diagnosis is more than sending in a prescription via telephone yet we should also understand that quite possibly what Gary is speaking of is relating to only ‘certain’ audiences–like those younger men who do not like to even attempt the doctor’s office? Or even those like myself who feel as if being treated as primarily a “chart number” at the office and footing a bill for a few hundred dollars later would really rather stay home while sick and just phone it in–because the physician-patient relationship never changes. Not to say I discredit the amount of intelligence and work that is put forth into an M.D. status, but rather also don’t want to discredit the amount of technology available to have a more cost-efficient health care system?

  • Anonymous

     Yes, but it COULD work for all the other 10+ scheduled visits throughout that year to keep costs down? That’s what we should be looking at to make things happen (the possibilities of it working) for organizations to fund this type of an idea in the future… just as new businesses happen with venture capitalists! The U.S. has to pay for health care already and therefore someone else (not to exclude ourselves) should pay for a working system. Quite possibly, physicians could also work based on the quality of care versus its quantity by minimizing those patients that only want the “in and out” visit? Bottom line: Choice.

  • http://www.facebook.com/pgonzalezcolaso Patricia Gonzalez Colaso

    I’m surprised that you propose, in the name of efficiency, spend tens of millions to avoid wasting 4 hours out of 8760 you have in a year, because you are too impatient to actually TALK to your physician and take care of your health…interesting

  • http://www.facebook.com/pgonzalezcolaso Patricia Gonzalez Colaso

    I’m surprised that you propose, in the name of efficiency, spend tens of millions to avoid wasting 4 hours out of 8760 you have in a year, because you are too impatient to actually TALK to your physician and take care of your health…interesting

  • Michael Smith

    I enjoyed your post and the commentary. 
    A significant part of the patient encounter is all about collecting data
    from the patient about the reason for the office visit, whether being seen for
    a routine appointment or ongoing treatment for chronic disease.  The necessary data as identified by your
    physician is captured, documented, incorporated into the medical record
    (paper/electronic).

    A few examples of data collected are  weight, height, temperature, blood pressure,
    reflexes, lab work, diagnostic imaging.  Data
    is collected by a variety of personnel for example, Medical Assistants, Nurses,
    Physicians, Lab/Imaging techs with a wide range of skills and training.  The technology exists today and is commercially
    available to change not only where and how the data is collected, also the
    frequency that the data is collected.  A
    great deal of this can happen outside of a traditional medical settings, in
    your home or on you person via a smart phone.  

    This would create an opportunity to change the nature of your
    relationship with your health care provider.  Armed with longitudinal data the physician/clinical
    staff can evaluate the data and proactively take action.  Appropriate action could include a range of
    recommendations: if critical, call ambulance or go to ED; schedule an
    appointment, modifications to diet, changes in medication levels are a few
    examples.  In my view the office visit is
    not going away, it will be complemented by appropriate technology.

    Embracing such a change requires detailed planning, preparation,
    and communication to all parties involved. 
    In addition to the technology components, plans need to address data
    security and patient privacy. The big elephant in the room is how physicians be
    reimbursed for these services. 
    Reimbursements changes are being evaluated at the federal government
    right now, pilots are underway across the country.

  • http://twitter.com/Dr_Steve_Ponder Stephen Ponder

    Yes. This is a viable and successful model for on-line health care delivery for persons with diabetes. As above, this has been done for 4 years now!

  • http://www.facebook.com/profile.php?id=762893788 Dave Miller

    Robert,

    Your idea with a webcam is fine except that it is necessary to actually touch the swollen ankle to properly evaluate it. A webcam is not enough to get the job done.

    As far ask asking your a question about your body, this assumes that you know what is normal and what is not. Different is not always bad and same is not always good. Not to mention you might not even be aware of whatever is causing the problem. Many nasty problems (like cancers) have only very subtle signs and symptoms in the early stages when they are more easily treated. Again, this is why we sit through years and years of medical training. If it were as easy and you and Gary suggest then you wouldn’t need to pay us for all this fancy evaluating and examining.

    Interestingly, folks seem to think it’s a good idea for their doc to spend more time with THEM but get really upset when he or she spends more time with THE OTHER GUY because it causes them to have to wait longer. Perhaps what we need to do is just calm down and be a bit more patient, understanding that if the doc is being careful to spend more time with the other guy, he or she just might spend more time with you (provided you’re not a jerk, that is).

    • http://www.facebook.com/people/Gary-Patterson/100002200271255 Gary Patterson

      Dave,
      I’m not suggesting that Doctors don’t get paid for their services or devaluing the services they offer.  I’m suggesting that the use of technology could augment the processes in place now and allow more time for doctors to spend with the critically ill.  As far as the webcam, there’s nothing wrong with a Triage nurse looking at the ankle and directing the patient to an ER if critical, or scheduling an immediate visit with the doctor so that he can put his hands on it.  The fact is that not everything requires a doctor’s touch.  Therefore, use the technology to make sure that we’re using the doctor’s time best while making it more convenient for the patient.
      Gary Patterson

  • Neil Baum

    I see great potential in this concept.  This can also apply to specialists as well.  For example, I am a urologist and I envision a patient with BPH contacting me to discuss their medications. They would complete a five question survery on their lower urinary tract symptoms, i.e., how miuch frequency, nocturia, urgency, and post micturition dribbling they have, and what are the side effects of their medications.  The PSA results would be checked and then adjustments in the medication could be safely made and advice given.  I have done used this approach for 200 men with BPH.  They were evaluated first in the office with a complete history and physical including a digital rectal exam and a PSA test.  The study consisted of nearly 100 patients whose medication was monitored via the telephone with my nurse and contacted the office every three months and returned annually for a DRE and PSA test. The other arm of the test included 100 men who came in every 3-6 months for a symptom check and a digital rectal exam.  Those who participated in the telemedicine program were more satisfied with their care than those managed by the conventional office visits every 3-6 months.  Also, there were no cases of prostate cancer that were missed.  
    I believe this same approach can be applied to women with overactive bladder, men with ED, and women with uncomplicated UTIs.  Medicine needs more out of the box thinking and Gary Patterson has us thinking about harnessing this technology.

    • http://www.facebook.com/people/Gary-Patterson/100002200271255 Gary Patterson

      Neil,
      Fascinating comment.  Thanks for taking to time to respond.  Your approach to the BPH patients is exactly how I envision routine encounters to take place.  Now, the tricky part, “How are those encounters compensated for the physician?”  I feel that doctor should be compensated on services rendered, whether it is in a doctor’s office visit or not.  How did you work that out?

  • http://www.facebook.com/people/Gary-Patterson/100002200271255 Gary Patterson

    Boricuaenarizona,
    Your comments reflect the arrogance that is associated with medicine that is causing a backlash amongst your patients.  You talk of developing a relationship with your patients while not listening to them.  My comments have merit because I’ve spent more time being a patient than you’ve spent being a doctor.  Yet, you dismiss my comments out of hand because you don’t value me and my experiences.  How can you develop a true patient relationship if you won’t allow patients to participate because you don’t value their input because they don’t have the required background.  I’m not suggesting that we dictate how medicine is practised, only that you consider the patient’s point of view.  That is treating people, no numbers or cases.  Your suggesting that there is not merit in doing that suggests that, despite your attempts to the contrary, you are indeed treating something other than patients.

    • Anonymous

      Gary:  Arrogance comes out from your reply.  You post:  “My comments have merit because I’ve spent more time being a patient than you’ve spent being a doctor.”  If you have spent a total of 30 years by a patient, you are one sick puppy.  I do not know of anyone that has spent even two years, totaltime, being a patient.  By the way, I am also a patient and have a dad dying from cancer.  I have spent many hours in hospitals and doctor offices taking care of him.  I have the advantage of being in both sides of the coin.  Finally, the one comment that shows your arrogance comes  when you say:  “the patient must put their life on hold while they return to the doctor’s office”.  Going to the doctors office is not putting your life on hold.  It is actually an investment with the purpose of providing quality and quantity to your life.   If your are too busy, skip the doctor’s visit. 

  • http://www.facebook.com/people/Gary-Patterson/100002200271255 Gary Patterson

    Patricia,
    Nothing that I proposed costs tens of millions of dollars.  In fact, there would be tremendous savings for physicians and patients.  Actually, it’s not that I’m impatient to TALK to the physician, just that it appears to be a process that could be completed much easier for everyone involved.  Therefore, the most critical patients, requiring hands on care, could be seen.  The technology would be used as Triage to determine when an office visit is needed. 

    Think about it…as a parent of an active child, all types of situations arise where medical attention might be necessary.  My daughter just fell out of a tree last week.  At first she was experiencing extreme pain in the ankle.  We thought about x-rays but tried ice over night.  Things got a little better so we kept to the ice/heat regieme.  It seemed to work.  But now she’s experiencing pain when she chews.  What to do?  Tommorrow, I’ll be taking her to the urgent care down the street to get x-rays to rule out structural damage to the jaw.  Throughout this entire process I would feel far more comfortable having her pediatrician on board and directing my actions.  They have her history and her records.  They have treated her since birth.  However, they have moved and getting to them is 45 mintues across town.  Also, they are only open until 4:30.  Kids have crisis 24 hours a day. 

    What would be nice is to be able to make a call, talk to a triage nurse who could help me make the determination on actions to take based on the best medical advice.  Turns out the ice/heat was the appropriate course of action…but it was a “best guess”, not based on definitive evidence.  Had she looked at it and determined that the range of mottion was good and swelling not too bad so ice was most appropriate, I would have felt a lot better. 

    By the way, I’m not remotely suggesting that physicians don’t get paid for this service.  Quite the contrary.  I believe that those physicians who adopt this approach, or something similar, should be paid for the Triage and services rendered similar to an actual office visit.  Afterall, I, as the patient, am getting treated, regardless of how it’s done.

  • http://www.facebook.com/people/Gary-Patterson/100002200271255 Gary Patterson

    Dr. Kumar,
    I would agree with that.  I would suggest that we don’t take that away.  That’s where the intuition of the Triage comes in.  If they feel that the visit would be beneficial beyond the simple treatment, they would make an appointment for the patient.  I don’t want to ever get away from the human element in treating patients.

  • http://www.facebook.com/people/Gary-Patterson/100002200271255 Gary Patterson

    Dave,
    It’s not snarky at all.  This my first attempt at widespread bogging.  I must admit, I was apalled at the typos I saw when rereading my post.  I’ll do better next time, I promise.  Thanks for bringing my attention to it.

  • Security IT Professional

    And who at the pharmacy will verify it is the actual patient sitting at the BP machine and not someone else?  I wouldn’t want to “assume” the piece of paper handed to me without me witnessing who actually took the test was a valid reading. And who is responsible for calibrating the machine, is the physician/pharmacist aware of potential issues when it isn’t calibrated correctly or out of calibration?

  • http://twitter.com/Gregmogel Greg Mogel

    Really interesting posts and replies.  I believe that the idea that ‘technology’ automatically detracts from ‘relationship’ has been a concern in healthcare since…well…forever.   I would propose that in the age of Social Media, we can finally move past this concern.  The ability of a provider to engage in relationship and trust-building with a patient is neither enabled or disabled by technology.  If the provider and patient are motivated to form bonds…they will be formed and technology will enhance it.  If one or both are unable or unwilling, they will use technology to further their distance from one another.