The Nurse Will See You Now

This post was originally featured on EMRandHIPAA.

The Atlantic just wrote a piece highlighting the growing trend of non-physicians (commonly referred to as midlevels) providing healthcare. The reason is simple: supply and demand–more precisely, a fixed supply.

For any location where a patient demands healthcare services, there is only a binary result: either there is a qualified healthcare professional available to deliver care, or not. This slide (from Pristine’s investor presentation) illustrates this:

The supply and demand problem is further compounded by an archaic regulatory system. The path toward becoming a physician, at least in the US, is so arduous that the decision to pursue becoming an MD must be made by age 18 or 19. Even if a huge cohort of 18 year olds suddenly decided they wanted to be physicians, the artificially capped supply of available residency slots each year stimies traditional supply and demand economics.

Nursing, on the other hand, has a more varied cohort in terms of age of entry. Many nurses don’t enter the profession until well into their late 20s or 30s. The same is true of physician assistants. This has resulted in a more liquid supply of non-physician practitioners, and these non-physician practitioners are available to respond to the influx of new patients resulting from the ACA, and to the growing number of retiring baby boomer population.

Given the fixed supply of physicians, there are two fundamental ways to solve the supply and demand problem: make physicians more efficient, or substitute physicians with others who can do an equally good job for a given patient’s needs.

The realities of practitioner supply suggest that nurses and other non-physician practitioners will deliver an increasingly large percentage of healthcare services. Physicians will be relegated to the “high end” per Clayton Christensen’s disruption theory. That could manifest itself in a future in which midlevels deliver primary care and triage more acute conditions to “higher end” specialist physicians.

The greatest challenge in the triage-centric model led by midlevels is the (historically quite poor) communication among healthcare providers. We will need a robust technological infrastructure to support the seamless transfer of patient data among providers. Additionally, we’ll need more capable communication tools to empower providers to connect with one another and with patients regardless of location.

Telemedicine seems to be taking hold to power a future in which location is irrelevant. Interoperability is improving within health enterprises, though there are some signs that community health information exchanges (HIEs) are notdoing as well as many had hoped.

At some point down the line, we’ll likely look back and wonder why location mattered so much. It shouldn’t, and because of telemedicine, and liquid data connectivity, it won’t.

Happy Mother's Day! Telemedicine Edition

This post was originally featured on EMRandHIPAA.

In honor of Mother’s Day, I thought I’d write a post highlighting how telemedicine can benefit mothers caring for their children.

Many children can get up to 6 ear infections per a year. Everytime it happens, children complain, and inevitably mothers take their kids to the pediatrician. In most cases, the mother already knows what the problem is (because it’s frequent and easy to diagnose), but yet she has to drag her child to the doctor, leave the kid in a room full of other sick children for half an hour, only to spend 5 minutes with the pediatrician to get a prescription for antibiotics. Then she has to drive with her child to the pharmacy to pickup the medications, and then get her child back home. Meanwhile, she’s falling behind on work.

What a pain. I can’t imagine fighting that battle even once per year, let alone 6 times!

Healthcare shouldn’t be hard. And in my cases, such as the pediatric ear infection, it’s not. What if mothers bought a Cellscope, took a picture of her child’s ear, sent it to her doctor, then received antibiotics from PillPack the next day? Or better yet, what if the medications arrived via drone delivery within an hour?

I’m optimistic that 10 Mother’s Days from now, moms across the country won’t have to deal with so much frustration to solve what is such a simple problem.

The Pristine Story: Springing Ahead

Since the last episode of the Pristine Story, we've been busy as springtime bees!

Since announcing our launch at Brown University, we've gone live at three additional hospitals, with several more coming in May. We're holding back on PR for a bit, but will have some big announcements in the coming weeks, so keep an eye out for those.

We're not just busy at home, though...

HIMSS INNOVATION SUMMIT

Dr. Paul Porter (from Brown University) and Kyle will be presenting at the National Healthcare Innovation Summit in Boston.

They'll discuss Brown's experience using Glass for telemedicine in the ER, and present data on how Pristine's solutions dramatically improve efficiency in the care delivery system.

ATA ANNUAL MEETING 2014

If you're headed to the American Telemedicine Association Annual Meeting in Baltimore, come visit us at Booth #1814. We'll be the ones in clever T-shirts and Google Glass.

In fact, we're giving away a Google Glass unit to one lucky ATA attendee, so make sure to stop by our booth and enter our raffle!

Engineering Update
 
Our engineers led the most recent meeting of the Austin Google Developer Group (GDG) diving into the innards of WebRTC on Android.

Keep an eye on The Looking Glass (our engineering blog) over the next few days for more on how Pristine uses WebRTC, our slides from the GDG meeting, and more.
 
Finally, while it may be busy in the land of Pristine, we still find time to commit our thoughts to prose. To wit, our recent blog post (penned by Kyle) that examines the difficulty in reducing the cost of care.

And if you need more material to for your week's reading. There's plenty more analysis, commentary, and forward-looking thought on our blog. Enjoy!

That's it for this installment of the Pristine Story, stay tuned for more!

Until next time,

Healthcare Entrepreneurship-as-a-Service

This post was originally featured on EMRandHIPAA.

We are witnessing a dramatic unbundling of the services that power business. Almost every aspect of business can be unbundled into a monthly service.

My startup, Pristine, runs on a number of unbundled cloud services that until recently, would have traditionally been outsourced to HR firms or mega-IT companies. We run Pristine on ZenPayroll, RelateIQ, Google Apps, Expensify,Maxwell Health, Xero, Resumator, MediaTemple and more. Similarly, we’ve built our flagship service, EyeSight, on top of a broad array of development tools and services (check out the Pristine Engineering Blog to learn more about how the sausage is made). We’ve made it a priority to invent and do as little as possible by utilizing 3rd party stacks and services everywhere possible.

Healthcare is not immune to this trend. There are a number of companies that are unbundling health IT entrepreneurship:

• Catalyze – HIPAA compliant hosting and data APIs as a service
• Accountable – HIPAA compliance and training as a service
• Validic – quantified-self data as a service
• Allscripts Developer Program – EMR APIs and distribution as a service
• AthenaHealth Marketplace – EMR APIs and distribution as a service
• Greenway Marketplace – EMR APIs and distribution as a service
• Twilio - Messaging and telephony APIs as a service
• Capsule / iSirona - medical device integration as a service
• SureScripts – eRX as a service
• TigerText – HIPAA compliant messaging as a service

This list should be 10x longer than it is. With all of the capital and startups entering the health IT space, companies providing the infrastructure to accelerate growth will thrive. As the old saying goes, “During a gold rush, sell pickaxes.” The companies listed above are selling pickaxes to proverbial gold miners.

I’ll conclude this post with some areas that can be commoditized as a service. Feel free to leave comments on other areas or companies that I missed.

• Interoperability as a service (in lieu of HL7)
• HIPAA compliant videostreaming as a service
• HIPAA compliant image / video sending as a service
• Analytics as a service

The Feds Are Supporting Telemedicine

This post was originally featured on EMRandHIPAA.

The Federation of State Medical Boards (FSMB) recently passed a model telehealth policy that promotes virtual visits for first-time encounter. This is notable for 2 reasons: first, many state medical boards liberally borrow from the federal boards, and second, this marks a shift from the old model in which patients were encouraged to see providers in person before engaging in telemedicine consults.

It’s encouraging to see the old, arbitrarily restrictive model fade, in favor of one where patients can begin building a relationship with their physician without travel. Indeed, people meet on the internet all the time; why can’t patients meet their care providers the same way?

The old model was arbitrarily limiting access to care, and thus driving up costs and driving down quality. Under the new model, patients should finally be able to login to a web service and be connected directly to a qualified physician that payers will cover. For telemedicine companies like American Well, Doctor on Demand, and others, this is a major coup.

This combination of technology and new guidelines will reduce ER visits, improve access, and ultimately reduce costs. Once it’s easy to get access to preventative medicine, patients will actually partake in preventative care. As a simple example to illustrate this, let’s examine my wellness check up habits.

I’m a healthy young male. I haven’t been to the doctor for a check up in close to a decade and have no intention of going. The process of booking an appointment, leaving my job that I love, and sitting in a waiting room are enough to deter me from ever going to the doctor. But if I could step into a private space and consult with a physician via a video consult for 15 minutes, I might actually get an annual check up. If the physician discovered something concerning and asked me to come, I would actually come in. But I would never come in for an in person visit without an explicit reason to. It’s not worth the pain and headache of going into the doctor’s office unless I have a reason to; the only way to achieve preventive medicine at scale is to make it easy for patients and providers alike.

Ambulances, ERs, and urgent care centers should expect a similar change in their operations. In these environments, specialists can now be reimbursed for first time consults with patients across a range of devices – iPhones, iPads, Androids, Macs, PCs, and even Google Glass. Neurologists can beam into ambulances for strokes, cardiologists for cardiac resuscitations, and trauma specialists for trauma cases. The opportunities are really endless, and my company, Pristine, is proud to lead the way in these new hyper-mobile telemedicine environments.

On the other hand, the new guidelines set forth by the FSMB aren’t all positive. Perhaps most perplexing, the FSMB did  not classify messaging and audio-only phone calls as telemedicine. They didn’t strictly forbid either activity, but they made it clear to payers and providers that live, synchronous video is necessary for reimbursement. In light of the shift to ACOs and value based models, this is perplexing. It’s been suggested that Kaiser Permanente and Group Health physicians reportedly spend up to 2 hours per day interacting with patients through asynchronous messaging.

Despite some setbacks in the new standards set forth by the FSMB, I’m incredibly excited about the future of telehealth across the continuum of care. The new model put forth by the FSMB is just the first of many steps toward a healthcare delivery system in which telemedicine powers the majority of care delivery across the country.