For over two thousand years patients and physicians have come together in the context of “the visit”. During this physical encounter, information is shared that leads to a diagnosis or therapy. Since antiquity, the history and physical exam have been the primary source of relevant information, and the physician often came to the patient. In the modern era images, laboratory tests, and other technologies have broadened the information sources, and it has become more common for the patient to visit the physician. But in either case, access has been defined as the ability to have a physical encounter between a patient and a provider.
However connected care—the use of telehealth, wearable sensors, mobile applications and other internet-connected medical devices—is rapidly changing how diagnostic and therapeutic information is shared. Through connected care, providers can monitor patients and communicate with patients from remote locations, and on a nearly continuous basis. Feedback from these devices can also help patients more actively engage in their own health care.
While we are still in the early phases of connected care, the enabling technology market is growing rapidly. The medical sensors market is estimated to reach $15 billion by 2022. The larger telemedicine market is projected to climb 19 percent annually. Today, people use more than 515 million wearable, implantable, mobile health or fitness devices around the world.
The proliferation of connected health technologies is redefining the notion of access so that it is no longer tethered to the concept of a physical encounter, i.e. “the visit”. It is, rather, the totality of information sharing interactions – whether by e-mail, phone, sensor, mobile app, video conference or an in-person visit.
This “connected access” is more appropriate for the chronic diseases that have become part of modern life. Diabetes, congestive heart failure, chronic obstructive pulmonary disease and arthritis cannot, in general, be adequately addressed in a series of 12-minute physician visits. To optimize management, particularly when there are multiple co-morbidities, requires ongoing communication between patient and providers, and careful adjustment of therapies as the patients’ conditions fluctuate. While the visit-based paradigm may have been appropriate for the infectious illnesses, and traumatic events that dominated in the past, it is not the optimal model for chronic conditions that dominate the present.
In this model, access itself is provided in varying “doses” depending on the needs of the patient. In some cases, a weekly call with the nurse will suffice. In other cases daily communications by e-mails, texts or calls with the nurse or coach will be required, supplemented by periodic video conferences and in-person visits with the physician. The “dose” of access is adjusted based on the clinical needs of the patient at that time.
Despite the rapid emergence of enabling technologies, most care is still delivered in the more traditional visit based models. That is due in part to fee-for-service reimbursement structures that favor in-person visits. Value-based payment models, in which providers are reimbursed based on outcomes rather than visits, are more conducive to connected care and the access models associated with it.
The other important component of connected access is team-based care. Access does not necessarily require an e-mail or conversation with a physician. However, for communication with a coach, a nurse, a nurse practitioner, or a physician to be most effective, they must all be part of a coordinated team and have reliable mechanisms to share that information with each other. This will require redesigned workflows and team-based practice models. Patient-generated data must flow more fluidly among providers, requiring better data integration, visualization, and analytics. New approaches to measuring access adequacy are also required.
The Department of Veterans Affairs and Kaiser Permanente, which are unburdened by fee-for-service payment models, are well-positioned to achieve this vision. Through the Office of Connected Care, the VA is aggressively integrating telehealth into its care model. In 2016, 13 percent of veterans received elements of care virtually-a total of 2.29 million telehealth visits, serving a total of 782,000 veterans. Additionally, veterans who enrolled in Home Telehealth for chronic care management had a 33 percent and 53 percent decrease in hospital admissions and bed days of care, respectively. This contributed to about 89% of veterans providing a high satisfaction score for telehealth services.
We are on the cusp of an inflection point in the history of medicine. Technology has the potential to free us from the limitations and inconvenience of the visit based paradigm. Connected access will enable us to calibrate the right dose of access, through the right channels, at the right time, to meet patients’ needs.
Photo: Natali_Mis, Getty Images
