“So how can health systems and clinicians provide patients with an improved, consumer-friendly experience while also making strides to decrease provider administrative burden and burnout? They need to embrace virtual care beyond just video visits and look toward asynchronous telehealth. Asynchronous care allows providers to treat patients for common, low-acuity conditions online without a real-time, face-to-face interaction. It automates both the patient interview and clinician documentation, and provides clinical decision support while maintaining provider autonomy, keeping the clinician in control of diagnosis and treatment. Looking ahead, asynchronous telehealth holds unlocked potential for improving access and convenience for patients, reducing physician burnout, and driving efficiencies in care delivery to ultimately lower costs and improve outcomes.”

Christina Chen is a family medicine physician.

She shares her story and discusses her KevinMD article, “Debunking the myths around asynchronous care.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at kevinmd.com/rate, and subscribe at kevinmd.com/follow. Today on the show we have Christina Chen. She’s a family physician. She wrote the KevinMD article “Debunking the myths around asynchronous care.” Christina, welcome to the show.

Christina Chen: Thanks for having me, Kevin.

Kevin Pho: We’re going to get to the article in a little bit, but first off, can you share your story and journey to where you are today?

Christina Chen: Yeah. I’d say early on in my career, I worked in a variety of clinical settings, including community health clinics, fee-for-service organizations, as well as your typical HMO and ACO organizations. Even though the settings were different, the challenges were often the same: process inefficiencies that ultimately fell on me as a physician to make up for, being bogged down by documentation and administrative burdens, and really not being able to just practice medicine. It was really discouraging and frustrating, and honestly, I was really unhappy.

So in 2015, I left the traditional brick-and-mortar clinic setting, hoping to find a way to use my medical education and training in a nontraditional way. At the time, I had no idea what that would look like or even where to begin my search. By chance, I landed two separate independent contract roles in the emerging field of telehealth. My first one was as a provider for Amwell’s Online Care Group, where I saw patients via video for a variety of health systems and payers across the country. I think at one point I had nine or 10 different state medical licensures. My second independent contract role was writing clinical content for Bright.md’s asynchronous care platform.

It was really interesting to be in both of these roles in the really early days of telehealth. Back then, there was a lot of skepticism around treating patients without being able to lay hands on them or do a physical exam, and even more so about treating patients asynchronously, without any sort of direct interaction. I admit I had my doubts as well, but with time and experience, that skepticism started to fade. I found that there was a lot of overlap between the types of conditions I was treating patients for via video and the conditions that I was writing clinical content for: mostly those low-acuity, common conditions that could easily be treated symptomatically with over-the-counter medications, women’s health concerns, UTIs, yeast infections, birth control, or patients who simply needed reassurance that, “Yes, this will get better on its own, and no, this isn’t something that you actually need to go in and be seen for.”

So in the middle of 2018, I officially joined Bright.md as a physician editor, really focusing my time and energy on helping to develop, grow, and improve the asynchronous care platform. Since then, my role has slowly expanded to what it is today, as medical director. A large chunk of my time is still spent working with our content team to create and maintain all of the clinical content that is in our platform, but I also work a fair amount now with our sales and marketing teams, our customer success teams, as well as our product teams.

Kevin Pho: So what are some of the challenges that you face moving from a clinical role into the role you’re in now?

Christina Chen: I think a lot of it was really personal, thinking, I went to medical school for all this time, and I did residency and all this training, and now I’m not seeing patients anymore. So it was really a personal, internal battle of “Am I still a doctor? Did I do all of this for nothing? Or is it enough that I’m in this different realm now, still treating patients indirectly and really trying to improve health care as a whole?”

Kevin Pho: All right, let’s talk more about asynchronous care. Your KevinMD article is titled “Debunking the myths around asynchronous care.” Now, for those of you who get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Christina Chen: Yeah. I think I would start with saying, what is asynchronous care? A lot of people don’t know what it is, and that’s understandable. It’s really a new modality of care. Asynchronous care allows providers to treat patients virtually without a real-time, face-to-face interaction, and for us at Bright.md, that currently applies to common, low-acuity conditions. We do this by automating both the patient interview and the clinician documentation. We also provide clinical decision support while maintaining provider autonomy, keeping the clinician in control of the diagnosis and treatment plan at all times.

So again, there’s a lot of confusion and misconception around asynchronous care, being that it is a relatively new modality of care. But I also have the unique role of partnering closely with clinician executives and providers as they experience the power of asynchronous telehealth. Not only are they using it to deliver high-quality care, but now they’re also advocating for its value as a telehealth tool. I really believe that, unlike other digital tools out there, asynchronous care really has the potential to transform health care for all parties: the patient, the provider, and the health system. So the article I wrote really goes into what asynchronous care is, what it isn’t, and then addressing some of those common myths.

Kevin Pho: So tell us some of these common myths about asynchronous care, and tell us the truth that punctures those myths.

Christina Chen: Yeah, gladly. I would say one of the main ones we hear is that asynchronous visits are not as effective as a face-to-face interaction, whether that be via video or in person, because there isn’t that real-time interaction or that physical contact with the patient. But I think the truth is they can certainly provide the same quality of care for certain conditions. Through thorough, consistent digital clinical interviews that are evidence-based and dynamically changing based on the patient’s responses, we mimic the history-taking process that normally takes place in any synchronous interaction. In fact, a lot of clinicians tell me that the asynchronous interview is more comprehensive and more thorough than they often have the time or capacity to do when speaking directly with the patient.

Once that digital interview is complete, the patient’s responses are used to generate a progress note for the provider to review, and we also show them a list of relevant, treatable diagnoses and their associated evidence-based treatment options. This allows for delivery of care that meets and often exceeds national quality standards, and it’s done in a fraction of the time. Our data shows that providers can deliver care for these low-acuity, common conditions in less than five minutes, and that includes completing all of their clinical documentation. And the patients are waiting less than 10 minutes between the time they submit their interview and the time that they receive a diagnosis and treatment plan. So that’s pretty remarkable.

Another common myth that we hear is that asynchronous care means chatbots and symptom checkers, and I think it’s really crucial to make a distinction here. First and foremost, asynchronous telehealth can provide end-to-end, definitive care, while most chatbots and/or symptom checkers can only give the patient a list of possible diagnoses, “Here are the five things that your symptoms could represent,” or they just direct the patient to another venue of care to get that definitive care.

I think also chatbots and symptom checkers are designed specifically to remove the clinician from the patient interaction, and that’s the opposite of what asynchronous care does. There’s no direct, real-time interaction, but there’s always a provider at the other end providing care for the patient. Although we offer clinical decision support, we’re not trying to replace the provider. The provider is always in control and has autonomy over how they diagnose and treat a patient, including the ability to escalate that patient to a higher level of care when needed.

Kevin Pho: So give us a case study or an example of how your solution would work in a typical primary care setting.

Christina Chen: Yeah, I think probably one of the ways that would be most helpful: All of us primary care docs get inundated with our inbox, right? Email messages that you’re trying to answer in between seeing patients, answering phone calls, and answering questions from your nurse. So let’s say you get an email message from a patient who says, “Hey, I think I have a UTI again. I haven’t had one for a year. Can you just prescribe me the antibiotics that I got a year ago?” Rather than having a back-and-forth email chain, “OK, can you tell me about your symptoms?” you send it to the patient, they maybe respond in an hour or two, and then you see that follow-up email. Oh, they forgot to answer one of the questions. I need to follow up with them and answer. So it goes back and forth, back and forth. That could last several hours, even several days, depending on how busy you are and how busy the patient is.

On the flip side, if a patient emails you and says, “Hey, I have a UTI again,” same email, you say, “Hey, why don’t I send you a link and have you fill out this clinical interview? It’ll ask you all of the questions that I need the information for in order to treat you.” That’s a one-time sort of interaction, right? And then you, or, depending on how you staff your asynchronous solution, a provider can simply review the chart note that’s been generated by that interview and provide treatment for that patient right away. So we’re taking a maybe hour-long to day-long process and cutting that down to less than an hour.

Kevin Pho: So a typical interaction, would you say, how long would that last?

Christina Chen: Yeah, so it typically takes a patient anywhere from 10 to 12 minutes to complete the interview. And then, again, it depends on how this is staffed. We have a lot of health systems that have a virtual care hub, which is a group of physicians who are answering all of these asynchronous care interviews, right? So if I fill out an interview, it may not go directly to my primary care doctor, but it will go to a physician within my health system or within my care group.

So again, 10 to 12 minutes for the patient to fill out the interview, and then from the time of submission to the time that they get a treatment plan is usually about six and a half minutes, and providers take up about three and a half minutes of that time. So it’s really a lot faster and more efficient for both the patient and the provider. And again, the patient is not having to get on video or have a broadband connection or drive into the clinic, and the provider, again, is having all of that information presented to them in a succinct way, where they can just agree or disagree with the diagnosis, change the diagnosis, sign the treatment, and then that’s it.

Kevin Pho: Now, you mentioned that this is available for a limited number of conditions. What are some of the more common conditions that asynchronous care can be ideal for?

Christina Chen: Yeah, so I would say the ones that are kind of top on our list are cough, cold, flu, and COVID, obviously, within the last two years. Rash is very common, pink eye, ear pain, and surprisingly, behavioral health is actually one of our fastest-growing interviews. Now, that’s not necessarily a low-acuity, common condition, but we have found that it’s really a need out there. Obviously, there’s a mental health crisis in our country, a lack of providers, and then the costs associated with mental health care. And a lot of patients still feel a stigma when seeking care for mental health conditions. So this is sort of an easy, accessible way where patients can start their mental health journey.

They fill out a clinical interview, most of which, for our behavioral health, is made up of validated screening tools, right, which are easily amenable to a digital format: the PHQ-9, the GAD-7. We screen for psychosis, mania, and substance abuse. And so that is really amenable, like I said, to a digital interview, and then we present that to the provider, and they have a variety of options, right? They can start the patient on anti-anxiety meds, they can start the patient on antidepressants, or they can refer to a behavioral health specialist within their system. We also have been doing referrals to digital therapeutics, like the Calm app or the myStrength app. So it’s really just getting that patient started on their mental health journey and getting them plugged into the health system.

Kevin Pho: A lot of times during a telehealth visit or virtual visit, we can get a lot of clinical information from that virtual face-to-face interaction. I can see what the patient looks like, they can show me stuff, and I can even see the background of what their home is like, and that gives a lot of clinical information. So if we needed that additional piece of information, what would be the next steps through the asynchronous platform?

Christina Chen: Yeah, so providers always have the opportunity to escalate patients to a higher level of care. If I’m a provider doing asynchronous care and I’m reviewing the chart note, and I feel like I just want to talk to the patient on the phone or do a quick video visit to ask some clarifying questions, they can always escalate that patient to higher levels of care. And then, depending on the health system, you can configure that to work however you want to. Do you send them a direct link to an on-demand video visit, where they would just go into the virtual waiting room and wait to be seen? And then you still have all of that clinical documentation that you have already gotten from their clinical interview. So it’s really easy to escalate patients for those conditions or those situations where you really need even just a short face-to-face interaction.

Kevin Pho: We’re talking to Christina Chen. She’s a family physician, and she wrote the KevinMD article “Debunking the myths around asynchronous care.” Christina, what do you see as the future in the next year or so in terms of the asynchronous platform and its adoption among primary care clinics?

Christina Chen: Yeah, it’s really interesting. There’s really been a growth of interest in asynchronous care, spurred on, again, by the pandemic. There are some silver linings, I suppose, to the pandemic. The types of conversations that we’re having with prospects and health systems are really different now than they were even six months ago, right? Six months ago, there were a lot of questions about the validity of this type of care, and now it’s more, “Huh, this is interesting. How can I make this work for me?” I think the tides are finally turning for asynchronous care, and that’s really exciting for us.

At Bright.md, we’re really looking to expand the scope of asynchronous care beyond those low-acuity, common conditions. So how do we use components of asynchronous care to improve other areas of health care? Could we apply the digital interview to conditions like diabetes, asthma, and CHF, right? Or can we have these digital interviews sit in front of a synchronous face-to-face interaction, sort of like a pre-visit interview, more comprehensive than that clipboard and paper you get when you check in at your doctor’s, right?

So what if a patient in a virtual or traditional waiting room is asked to complete a dynamic digital interview, and then that information is used to start an automated chart note for the provider before they even connect with the patient? How much time would that save a provider? And how would that change the patient-provider interaction from one of data gathering and documentation and typing on a computer to one of true connection, right? Because you have that history already taken for you. So these are all areas that we’re really curious and passionate about and exploring for the future.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Christina Chen: Yeah, I would say to truly harness the power of telehealth to change health care for the better, you need to think outside of the video visit box when it comes to your telehealth tools and solutions. Providers will often tell me that a video visit changes only the geography of a visit, right? It doesn’t change the time it takes to do the visit, the patient interaction time, or the time required to chart versus a traditional face-to-face visit. Patients often encounter the same frustrations during a video visit as they do for an in-person encounter, and that includes scheduling and long wait times in that virtual waiting room.

So for certain conditions, I think this is where asynchronous technology can really be powerful and transformative, and you can absolutely deliver high-quality care safely and efficiently without real-time interaction. And I think by doing so, there can be significant benefits for the patient, the provider, and even the health system as a whole.

Kevin Pho: Christina, thank you so much for sharing your time and insight, and thanks again for being on the show.

Christina Chen: Thanks for having me, Kevin.