How can technology innovation save primary care? [PODCAST]

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“I believe there is a formula that can reduce the risk of burnout and save primary care, rooted in one key objective: Remove work from primary care doctors and nursing staff’s plates immediately.

Easier said than done. And that’s where technology and clinical navigation must be leveraged — to assist, facilitate, streamline, and support. Where EMR messages, not requiring doctor expertise, are responded to by clinical navigators harnessing technology to guide patients to the right outcome. Where these teams of clinical navigators are integrated into the clinical pyramid and delegated all tasks that do not require physician attention.

Integrated technology + navigation = relief.”

Ronald Dixon is an internal medicine physician.

He shares his story and discusses his KevinMD article, “As doctor burnout climbs, can we save primary 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. Today on the show we have Ronald Dixon. He is an internal medicine physician, and he wrote the KevinMD article “As doctor burnout climbs, can we save primary care?” Ronald, welcome to the show.

Ronald Dixon: Thanks for having me, Kevin.

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

Ronald Dixon: I am an internal medicine physician. I started training in 1998 at Mass General. After training, in my last year, I did a lot of ICU care, and I was really fascinated by the difference between working in the ICU and then following up in your primary care clinic.

In the ICU, I would walk in and everything would be set up for me. I’d have the patients I needed to see to be rounded on first. Those were all highlighted on a board in front of me. When I walked into the room, I would be able to see the vent settings and be able to adjust them. I’d be able to see all of their hemodynamic parameters. They were very clear for me to visualize and then make changes on. Then I’d see the nurses’ notes, and I’d have to write a quick little note about what I’d done with that patient and then move on to the next patient that was prioritized for me by the nurses.

Then I’d go to primary care clinic, and I would be doing pretty much everything. Granted, I had a medical assistant, but I would be trying to gather data about patients that was really relevant to their home life, and I didn’t really have any of the data points. The patients coming into my office would come one by one with no real prioritization, and often I’d be missing data that would allow me to best take care of them.

So I was kind of comparing and contrasting what was happening in the ICU versus what was happening in my clinic, and that’s really what brought me to this idea of: Well, why don’t we try to get some information from patients in the setting that they’re in, from their home? Why do we focus so much on in-office care, especially in outpatient chronic disease, when it’s really the things that our patients are doing at home, and the data that you need from the home, that are going to help best manage that? That led me down the path of primary care innovation.

I was fortunate to be at Mass General and to be supported with a fellowship that allowed me to really investigate this idea of using technology to engage patients. I started doing some things that were probably seen as disruptive. I started emailing patients and sending them question sets about their chronic disease, like hypertension or diabetes. The same kind of questions that I would ask in the office, I’d just send them by email, and this was before HIPAA. It was like 2002, 2003. Patients loved it, and I thought I was doing a better job of managing them, and they were avoiding visits. Then I got in a little bit of trouble, because of course I was taking revenue off the table for the practice.

That made me even more interested in the methodology and this idea of getting data from patients where they are and making your practice more efficient by doing so. I was able to collaborate with some people at Mass General, some nurses and some other doctors, to do some studies about this. We tested things like remote monitoring, back with the BodyMedia device: If you look at skin impedance and you try to get people to increase activity, can you affect things like blood pressure and weight?

I started looking at telehealth, specifically video visits. We actually did the first study of video visits versus in-person visits in a primary care clinic while I was at MGH Beacon Hill. What we found that was really interesting was that it doesn’t save time, but you can still make the same diagnosis. You can still do the same E&M. But at the time it was so important to try to take things off of physicians’ plates. It was already 2009, 2010. We were already overburdened with the EMR, and I was getting overburdened with Patient Gateway messages, these long-form messages that patients would send.

That’s what led me to really think about asynchronous communication and how you can really formalize that. I actually developed a company, and with the help of Mass General I was able to launch a platform that allowed patients and doctors to communicate using question sets. Instead of a patient coming in for a diabetes follow-up, the question set would go out after 30 days, the patient would answer it, and then it would be returned to the clinician to make a decision. We put a patient liaison, who was a non-clinical person, in between to follow algorithms to let the doctor know if he or she needed to take an action. So really, this idea was to use technology and use non-clinical, navigation-type personnel to help make the doctor’s life easier.

That went well. We scaled it through the hospital, again with the help of certain incentives from Mass General, and we were doing really well, over 60 different conditions, and there was the potential of a spin-out business. Then Epic came along and said, “We’re going to take care of and do all of that.” I ended up leaving Mass General and went to work for Google Verily on a digital diabetes company called Onduo.

Probably two years into it, I got a call from some investors who had been looking at this company, Healthcare 360, and they called me back. It was during the pandemic, and they said, “We’re really still interested in what you were doing. We’d like you to bring that to another company based out of Austin, Texas, called Remedy.” So I did that. I left Verily and Onduo and ended up going to this company called Remedy, which is now rebranded into something called CareHive, that I’m now running.

So this is the original thesis of using technology to engage patients outside the office, leveraging non-clinical providers to take burden off of primary care. And then I think the third piece of asynchronous data is quantitative. When you ask question sets and you answer yes, no, and “How do you feel, one to five?”, that quantitative data is very powerful, because you can use that quantitative data to become predictive, and then start understanding who needs to be escalated to what, when. Those who don’t need to be escalated can simply be followed using technology and lower-level navigators. That’s really what we’re doing at CareHive.

Kevin Pho: All right, let’s transition to the KevinMD article, and I’m sure you’re going to be talking more about this. It’s titled “As doctor burnout climbs, can we save primary care?” Now, for those who didn’t 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?

Ronald Dixon: It’s really an extension of the work that I’ve been doing for years. But what happened was a reporter called me in my current role and said, “What do you think about doctor burnout? It sounds like some of the things that you’re doing could address it.” I spoke to the reporter, and then she said, “Would you be able to put me in contact with some docs who might be able to talk to me about this?” I said, “Absolutely,” because I know a bunch.

So I actually started calling some of my friends who are still practicing, and so many of them said, “Yeah, I don’t think I can talk about this, because I’m kind of too burnt out to talk about it.” That was a surprise to me. And then it made me think back to, how did we get here? That’s kind of what led me to write this piece, which goes through, how do we get here?

One, primary care has just been undervalued, right? With the way that we’re paid, the relative value of primary care work has diminished over time compared to the relative value of specialist work, and that’s how we’re paid, based off the relative value unit. Given that challenge, there’s been less money attributed to the work and then more administrative burden put on the primary care doctor, which adds to the primary care doctor being completely overwhelmed.

Secondly, there’s a lot of uncertainty. COVID provided tremendous uncertainty. There’s a lot of uncertainty in the industry, where everybody says it’s time to disrupt primary care. You have retail pharmacies saying they’re going to disrupt primary care. You have new entrants into the system, like Google and Amazon, saying they’re going to disrupt primary care. You have completely digital entrants into the market saying, “We’re going to disrupt and take over primary care.” So that degree of uncertainty, there’s no doubt that it leads to this idea of burden, and the fact that so many physicians feel like it’s not going to exist in 5 years, and 20 percent feel as if they’re going to be retiring in the next 3 years.

My work, and the work that I’ve done with colleagues at Mass General, really focused on taking some of that burden off, and the way to take the burden off is leveraging technology the right way. So not adding clicks, but using technology to take work away. Leveraging non-clinical providers to take work off the table. A lot of this messaging back and forth, if there’s not a real clinical decision that needs to be made, should be handled by somebody else. It shouldn’t be overcrowding providers’ in-baskets. And then using data, I think, to help make the decisions easier on who gets prioritized, who gets seen now, and who can wait.

Not everybody in primary care needs peanut butter, right? The peanut butter approach to delivering care, where everybody just comes in, you settle a problem, then you bring them back at a certain amount of time, doesn’t need to be the case in the modern age. If you do these things, you can unburden primary care without disrupting it.

Primary care is relationship-based. I think people really want relationships. It might be that the new millennials might not need the traditional primary care relationship, but as people age and they develop issues, and that’s just a part of aging, that relationship can be valuable. By leveraging technology and leveraging other people to help, who are not necessarily clinical but can guide patients, that could create a much better experience for patients, obviously. It’s much more modern, and a much better experience for providers, because they can focus on the things they need to focus on and bring joy back into practice through relationship-based practice again.

Kevin Pho: You and I are both internal medicine primary care physicians, and I’ve been hearing about technology-based disruptions or solutions for many, many years now, and yet here we are. We seem to talk about the same issues year after year, and really, to be honest, nothing really much has changed. So why is the status quo so powerful?

Ronald Dixon: I do think that the payment mechanism has made it extremely difficult to effect change, and finally, that’s changing. First there were kind of quality-type payments, but now we’re really looking into shared-risk kind of arrangements. What I believe is you need to stack the cards in favor of the provider. You have to give the provider the capacity to take work off their plate and make it easier.

Technology typically has not been subtractive. The EMR, for example, has made things more efficient in terms of billing and the ability to capture revenue for a payer, but it hasn’t made our lives easier. I think we need to figure out where we can insert technology to make our lives easier and leverage some of the new capacities for integration that really didn’t exist in the past 5 years.

Kevin Pho: One part of your story that struck me is when you said that you developed this innovative solution of asynchronous communication, but your institution then adopted Epic, and then you had to leave because Epic was going to, quote-unquote, take over that part of the interaction. Now, of course, Epic, as you know, is growing and is the largest electronic medical record system in the country. Do you feel that scenarios like that are going to stifle innovation for companies like yourselves, or companies similar to yours?

Ronald Dixon: I think in the past it may have. I think because there’s more openness with new standards like FHIR, for example, that really are forcing people to open up integration points. And there’s this thirst, I would say, both on the patient side and the provider side, to make things easier. I do think Epic has its place, but I’m not certain that the place is to make the lives of either patients or providers that much easier.

So therein lies the opportunity for companies like ours. We’re really focused on the patient experience and the provider experience, but we also believe that we can provide better outcomes, both clinically and financially, by leveraging this type of asynchronous-first navigation and leveraging guides to really connect with patients and guide them on their journey, at the behest of their primary care physician and the system overall.

Kevin Pho: What are the biggest obstacles that prevent technology startups like yourself, and innovative idea starters like yourself, from being more widely adopted by primary care offices around the country?

Ronald Dixon: I just think that there are so many barriers to getting seen, to getting visibility, to understanding what the golden opportunity is because of this burden. So I think there has to be an incentive. On the work that we’re doing, you want to make sure that there’s an incentive for the provider to adopt us, and there has to be an incentive for the patient to adopt us, or else we can just be seen as noise, until you actually start to work with the patient and have that experience, work with the provider and have that experience, and prove results.

We are extremely focused on what people call ROI. We want to make sure that once a patient comes through our system, there’s immediate value that’s created, both on the clinical side, so that you can see that the patient actually is getting better taken care of, and over time that should lead to better outcomes and fewer complications of a chronic disease. And then much more efficiency on the financial side, so that you’re eliminating the need for hospitalizations due to exacerbations and emergency room visits through these more frequent touch points and technology-enabled navigation.

Kevin Pho: We’re talking to Ronald Dixon. He’s an internal medicine physician, and he wrote the KevinMD article “As doctor burnout climbs, can we save primary care?” Ronald, you’re at the unique intersection of medicine and technology. What would you say are some of the top upcoming trends that we can expect in primary care from a technology standpoint?

Ronald Dixon: Definitely you’re going to see a lot more of this async data exchange, communication exchange, where it’s device-less remote monitoring; actual remote patient monitoring with devices; and the integration of things that are going on outside the office with what’s happening in the office, to make the care much more relevant to the patient.

I think another trend that’s really important is the payment trend, the move away from fee-for-service, which is a slow march. It’s something that we’ve been talking about for, I don’t know, 20 years. It’s definitely a slow march, but payers, specifically Medicare, are really pushing for that, because they’ve seen that there’s value in outcomes. There’s value in being transparent with clinicians around what works for their patients, and then in enabling technologies and enabling other companies like mine to get into that sphere, which allows them to be more effective with their patients.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Ronald Dixon: I think for the audience, it’s really that change is on the way. I think we’ve been talking about it for a long time, but when I wrote the article about burnout and spoke to my colleagues about burnout, it could seem like there’s no hope. But I do think that there is hope.

I don’t think that new entrants are going to completely take primary care away. I don’t think that Walgreens is going to replace primary care as we know it. I don’t think that Google or Amazon’s going to replace it. I think there will be alternatives, but there’s sanctity in the patient-physician relationship, and there’s sanctity in primary care. I firmly believe that we need to modernize and leverage technology and get help from navigator-type personnel to make our jobs easier, but at the heart of it, it’s this relationship-based care, and that’s not going to go away. I think people like me and companies like ours are really here to enable that.

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

Ronald Dixon: Thank you, Kevin.

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