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By Dr. Kevin Vigilante
The current care model is broken. Providers, especially physicians, are increasingly unhappy and exhausted. In a 2018 survey of 15,000 physicians, 42% reported being burnt out. Patients and physicians don’t have time to talk to each other, depriving patients of the caring relationships they seek, and denying physicians the healing interactions that feed their souls. Both are frustrated by documentation requirements that divert providers’ attention to a keyboard. Despite the recent surge in virtual care, the physicians’ schedule remains the ultimate arbiter of access, and the visit-based model perpetuates geographic and travel-based barriers to care access. Care is poorly coordinated among multiple providers, and chronic diseases are not monitored with adequate diligence. Essential data is not easily accessible to the patient or the provider, and diagnostic and therapeutic errors are still epidemic. This is not patient centered care. The time is ripe to redesign the care model.
The digital revolution holds promise. Patients have their chronic illness 24x7x365 – 8,760 hours a year. Connecting with patients two or three times a month is often not sufficient to monitor and manage multiple chronic diseases. Digitally enabled care, on the other hand, allows near continuous monitoring and enlists the patient more actively as part of the team. Sensors can monitor blood glucose, heart rate, blood pressure (BP), oxygen saturation, activity, sleep and other key functions on a near continuous basis.
Artificial Intelligence (AI) has the potential to decrease the burden of drudgery levied upon providers, and free physicians to spend more high value time with patients. It can filter out the “noise” from mountains of sensor data and identify the meaningful “signals” that providers need to act on. It can suggest diagnoses and therapies that may not have occurred to physicians caught in legacy thought patterns, and it even promises to liberate providers from the keyboard. Nuance, recently acquired by Microsoft in 2022, has developed an AI enhanced, cloud based, voice recognition tool that converts physician-patient conversations to a structured medical note – which would change the game entirely.
With this digital potential, it has become fashionable to label the next generation care model as “digital care.” But that would be a misnomer; bits don’t care – people do. Digitized information can only enable a different human approach to care. Fully realizing the potential of digital modalities will require a more robust approach to integrating team-based care with digital tools. A highly functioning team will allow the division of labor required to optimize care – especially coordinating care with other providers, providing more personalized coaching for behavior change, and breaking down barriers created by social determinants of health. Not only is it better for the patient, who is a key member of the team, it is better for providers. Good teams balance the work burden, develop camaraderie, build trust, solve problems together, and support each other; in doing so, they reduce burnout.
Of course, there are challenges to digitally enabled team-based care. The tradition of physician exceptionalism, the notion that the physician is superior and “presides” over other providers, can undermine the more egalitarian culture necessary for team-based care. Few physicians are properly trained to lead and manage teams. And, in the dominant fee for service model, the team is often constructed to support the efficiency of the physician and maximize throughput of patients – not to improve the patient’s, or the physician’s, experience of care.
There are digital challenges as well. Poorly designed digital products may exacerbate pressure on providers because often they have not been optimized for provider workflows. Virtual care tools and processes are often bolted on to existing workflows and may increase the provider burden. Furthermore, digital tools often exist on different platforms making it hard to integrate data to create a clinical common operating picture. Finally, the fee for service payment model does not incent prevention and a population-based approach to care, which is a strength of team-based medicine.
However, these challenges are addressable. For example, IORA health has created a culture that flattens hierarchy and enables all team members to contribute in a more meaningful way. They broadened and enlarged the team by including more coaches to educate patients and monitor their care in outpatient settings and help with behavior change. Consultations that once required a visit to a doctor’s office could take place via phone, e-mail, and Skype, and didn’t necessarily involve a doctor. These coaches help patients overcome social obstacles like transportation, food insecurity, and stable housing. IORA developed a customized IT platform that allowed for more involvement from all members of the team. This platform makes all relevant patient data available to those involved in care – doctors, nurses, therapists, health coaches, and patients, in a way that enhances workflows. IORA, which has a heavy focus on primary care for vulnerable populations, eschews fee-for-service in favor of a population-based payment model. IORA has driven improved patient outcomes and achieved substantial reductions in hospital admissions and readmissions.
Changing the Access Paradigm
The fusion of team-based care and digitally enabled care can redefine how we think of our access to health care. The traditional concept of access tends to be binary – either you get an appointment with a doctor or you don’t. If you don’t get one in a timely fashion, you wait. That is no longer the case with digitally enabled team-based care. In this model, the object of access is the team, which provides multiple points of entry for access and ongoing communication. Digitally mediated care enables that access to be independent of location – it can be in person, or through e-mail, text, phone call or video visit. The nature, intensity, and duration of the interaction with team members varies with the needs of the patient at any given point in time. Access is continuously titrated to clinical need much like a medication is adjusted. The ability to adjust the dose of access, as you would adjust the dose of insulin, is essential to care for patients with multiple comorbidities whose conditions may fluctuate week to week or even day to day. By adopting digitally enabled team-based care, this new future for health care is feasible.
The Path Forward
Practicing medicine is a privilege. It allows a level of human intimacy that is unachievable in most other professions. It should be a source of gratification for providers and comfort for those in their care. But for too many that is not the case. The confluence of the multimorbid disease epidemic, the long legacy of the physician as a solo performer, misaligned financial incentives, and poorly designed digital tools have made medical practice unbearable for many. We must reconstruct the care model, the incentives, the workflows, and digital technologies that support both providers and patients. This will make digitally enabled team-based care possible and give patients and providers the time and space they need to re-establish the relationships they cherish.
Dr. Kevin Vigilante is chief medical officer at Booz Allen Hamilton. He advises senior government healthcare clients at the U.S. Department of Health and Human Services, the Department of Veterans Affairs and the Military Health System. With more than 35 years of experience, he provides clients with thought leadership in a broad range of topics including: health system planning and hospital operations; emergency management; safety and quality improvement; analytics, informatics, and telehealth; and public health.
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