Even 20 years ago, it felt like the core practice of medicine was fairly untouched by technology. The biggest technological shift was the advent of the Electronic Health Records. And of course, we used technologies like imaging and tools every day -- but that is as far as technology extended into our practice of medicine (at least in terms of how we tended to think about it).

These days, technology is developing quickly... and its penetration into our medical practice seems to get faster every day. 

I spotted several fascinating trends that are part of this quick evolution -- and are likely on their way to a doctor's office near you.

As you contemplate the trajectory of technology in medicine, there are some trends you can ignore... others that are obvious... and then there are those that are definitely coming your way -- but you may not be as aware of. 

5 Fascinating Trends in Telehealth That Will Affect You Sooner or Later

• Many patients will choose not to use telehealth.
  In an effort to start making money off the telehealth market, JD Power (yep, the car people) are beginning to rate telehealth programs. Interestingly, their first survey shows that many patients are deeply skeptical of using telemedicine as a replacement for their doctor's visit. According to Fierce Healthcare, about half of respondents believe telehealth quality is worse than a regular visit, and that it's less personal than a regular visit. And -- 0% of patients who rate their health as "poor" use telehealth. This resistance and mistrust (founded or not) is going to be a crucial dynamic to understand as we find the best ways to move forward with telehealth. 
  
  
• Patients will lose all sense of boundaries (until we create them.)
  The connectedness between doctors and their patients has evolved over time. There were the days of family doctors making house calls... there were the days of beepers and answering services... and now there are the days of messaging via patient portals. Unlike past eras, there are no natural norms, boundaries, or protocols for this messaging. As Fierce Healthcare illuminates, "There’s nothing to get in the way of a [patient's] concern and the perception and expectation the physician should be available... what’s a reasonable time for a physician to reply to a message? What’s the liability if a patient sends a clinically urgent message during the night or on the weekend? And will pediatricians soon be dealing with messages from their adolescent patients, as well as their parents?"  Of course, this isn't a situation that can last forever -- eventually, we need to create boundaries and systems, even if technology doesn't. Our norms and practices will struggle to catch up to technology. But it's up to us to make them work for doctors and for patients.
  
  
• Alexa will be watching your every move.
  Alexa, the "always listening" speaker powered by Amazon has some incredible skills. "She" knows if you want milk added to the shopping list... and she may be able to hear if your breathing suggests you may be having a heart attack. Kaiser Health News looked at a "gold rush" of health companies looking to innovate around using Alexa for health goals. It seems likely that Alexa -- plus similar technologies -- will play an increasing part in our telehealth monitoring landscape. So it's up to us to find ways of making this work wisely and intelligently. 

Kevin Kelly, the futurist and technologist, says that there are certain inevitable trajectories or trends that technology will take. But it is up to us how we then guide and govern and use those technologies. I believe that the more quickly medicine adapts to the realities of technological change, the more we can guide that change in the best possible ways for us and for our patients. 

Curious about the future of telemedicine? Get our quick guide on hybrid store-and-forward here:

Many doctors avoid going to the doctor.

There are probably many reasons for that — among them, the reality that we can answer many of our own health questions. But I think there is also an unfortunate reality to the fact that doctors know how flawed the current medical system is… and they don’t have the patience to deal with it.

So I have to admit that I was interested to read a description of what sounds like the doctor’s office of the future. Although I was skeptical, I have to say — it sounds pretty good! But there are some important caveats to keep in mind.

A startup called Forward is trying to reinvent how primary care happens. It's part of an overall shift and exploration of tech-enabled concierge medicine... using different forms of telehealth to support an all-in-one paid medical model. 

First, you subscribe to Forward, as you would a gym. Called “tech-enabled direct primary care,” you pay a monthly fee that covers labs and care. The experience is meant to merge the best of hospitality, tech, and healthcare. "We're trying to make healthcare like all the other services we're accustomed to using in our lives,” Forward's Chief Medical Officer Nate Favini, M.D. told Fierce Healthcare

Admittedly, that’s a description that puts my hackles up. To me, healthcare should be much more than hospitality. Truly good healthcare isn’t about making sure patients are comfortable all of the time. It’s about collaborating with patients to go on a journey of their own healing.

But the reality is that Forward’s model has a lot of compelling elements. Patients don’t wait; every appointment begins on time. Costs are saved by reducing the number of support staff involved in patient check-ins and even taking basic stats (that’s done with a body scanner.) The care room has been reinvented to allow doctor and patient to face each other in a serene and comfortable setting. Every appointment is a luxurious 60 minutes and covers a variety of holistic elements, including things like nutrition and even genetics.

So much of what Forward is doing is simply better than how we do it today.

But I worry about a model like this for a few reasons:

• Patients should be treated as people, not consumers.
  The “shadow side” of a model based on hospitality is that we begin to view our patients as “customers” not as people whom we have a sacred duty to care for. In the new model, doctors become more interested in profit margins and satisfaction scores than they do about the Hippocratic oath… and perhaps giving patients the care they need, even if it’s not always the care they want in that moment.
• Everyone deserves excellent care, not just those who can pay for a membership.
  Although this membership seems affordable, I worry that having too many of the country’s healthiest people buying their own memberships could create a situation where we’re not considering healthcare as a community. Rather, that we’re considering healthcare as something that we must get for ourselves, above all.
• People forget that healthcare is both for primary care, and for situations when we are truly sick.
  Not all healthcare should be fun or comfortable. Sometimes healthcare is a battle for your life. In many cases, healthcare demands the highest level and intensity of care and collaboration. And that’s a reality that even a beautiful lobby can’t gloss over.

Long story short: I think what Forward is doing is great. Also: we need more than just prettier healthcare or easier healthcare or healthcare the way patients want it. We need to make better healthcare — and that involves patient experience as well as making sure healthcare providers can work in profoundly better ways.

Healthcare in the United States is struggling.

We need better care, more innovation, and to drastically cut the cost of care. We need everyone in the US to be insured, and we need to make sure that regardless of income, you have access to fantastic healthcare.

It is possible that small, incremental changes aren’t going to get us where we’re trying to go — it’s important for us to act boldly and to dare to rethink how we do medicine. But the reality is that our mindset tends to trap us into using even groundbreaking technologies in old fashioned ways. And a new VA program is no exception.

As Fierce Healthcare reports, the VA has gone in big with a new telehealth program. 

In a span of just 11 months from 2017 to 2018, veterans received care in 2.3 million episodes of telehealth. About half of these were video "visits" from veterans to providers; the other half was VA staff accessing or reviewing data sent via similar means.

It's inspiring to notice how much traction telemedicine has gained in the last several years. It has truly gone from something that very people understood or knew about — to something that many people will have contact with as a patient at some point soon. And I also applaud the willingness of the VA to adopt a new technology and implement it in an expedient manner. 

That said, I worry that the VA has found a more affordable way to provide care — having veterans have virtual visits with providers rather than in-person visits — but not a better way to provide care? In one way it is better: veterans don't have to leave home to be "seen" by a provider. But I worry that the quick telehealth virtual consult might lose the richness that an in-person visit can offer. For instance, perhaps the "doorknob" questions won't happen — those offhanded questions a patient asks once the doctor's hand is on the doorknob, on their way to another appointment... which often turn out to be the most important part of the visit. 

Beyond that, the expansion of these telehealth visits makes me think of another time in our history when we used a new technology in old fashioned ways. When the telephone was invented, no one could fathom wanting to have a conversation by phone — so the first phones were actually a tool to read telegrams aloud. We used our old fashioned telegram concept to shape how we used the new technology of the telephone. 

Similarly, we often use telemedicine as a "better version of the telephone" — and that's precisely what these VA telehealth visits are. Just as with the telephone, weak points of the system abound: no medical collaboration occurs because it is simply a 1:1 call; the case and information isn't archived or accessible to other team members or accessible for learning; schedules have to be coordinated for each visit to occur. It's using telemedicine as a fancier telephone — just as we initially used the telephone as a fancier telegraph.

I think it's important that we try to envision the highest and best use of the telemedicine technology we now have. To me, that means using it to facilitate asynchronous medical collaboration among medical teams. Because ultimately, that is the way to provide better care, not just cheaper care. 

If there is one thing we all agree on, it’s that healthcare is complex.

The health of any individual is, of course, complex — with thousands of variables in the matrix of health, illness, and healing. Further, healthcare itself is complex, with so many challenges and opportunities that it’s easy to lose hope that things can change or improve.

So it’s deeply heartening when we stumble across a healthcare initiative that is outrageously simple, but with profound results.

Recently, I stumbled across two healthcare interventions that are deeply effective but very, very simple.

First, a group of California hospitals implemented a simple post-hospital educational initiative to reduce MRSA infections. 2000 patients were given either education on preventing infections via hygiene or that education plus antiseptic for bathing, antiseptic mouthwash, and antibiotic nasal ointment. The results? MRSA infections came down by 30%, with the education-plus-supplies group showing the most improvement. No new technologies were pioneered; nothing expensive was implemented. Just a simple “care package” to send home with patients from the hospital.

Second, a Virginia VA hospital had its nurses spend extra minutes with patients plus spend $5 on a toothbrush and toothpaste to encourage patients to brush their teeth. The results? Non-ventilator cases of hospital-acquired pneumonia have decreased by 90%. So far, they estimate that they’ve saved 21 lives and reduced costs by $4.69 million. Pretty phenomenal results for something as simple as a toothbrush and a helping hand.

So is there anything that we can conclude from these two studies, other than celebrate the ingenuity of their pioneers? I think there is. 

2 Key Learnings From These Pioneering (But Simple!) Studies: 

• Simple and inexpensive can be best. 
  One thing that we love about iClickCare is that it's a simple, inexpensive way to do telemedicine -- no expensive new hardware or computers or huge software implementations required. Sadly, some in healthcare believe that complexity is always better -- so they'd almost prefer a more expensive, more difficult product. But these studies are yet another proof point of how misguided that approach is. 
• Real life trumps theory. 
  In both of these studies, the initiatives were thoughtful about the reality that patients would face as people receiving care (one in the hospital, and one after the hospital stay.) It's easy for us in healthcare to focus on the glamorous treatment -- like a sophisticated surgery -- and forget that something as simple as nasal ointment or tooth-brushing can save lives. Similarly, we believe it's crucial to collaborate across the continuum of care -- not just between specialists -- since often, aides or nurses or others on the team will have a more "real life" perspective that can help.

The bottom line? Don't be afraid to do what is right for your patients, even if it doesn't sound fancy. It's possible that the deeply un-fancy is what's going to save healthcare -- and save lives. 

For more stories of smart collaboration, download our Quick Guide:

In a conversation with a young doctor recently, she sighed as she considered her future as a physician.

“I just don’t think my job is going to really exist in a decade or two,” she said. “It’s all going to be computers and nurse physician assistants.”

It’s a scary thought — that doctors as we know them — won’t have a role in providing medical care in the future. But is it true?

The applications to the U.S. Patent and Trademark Office are always illuminating as to what is on the horizon in the world of science and technology. Patents reflect those innovations that may or may not have a business plan or a market, but often reflect the direction that technology is headed more generally.

So I was interested to note that Google is developing an electronic health record (EHR) that uses machine learning to predict clinical outcomes.

As Fierce Healthcare reports, “Google appears to have plans to develop its own electronic health record (EHR) for clinicians that gathers patients’ medical records and then leverages machine learning to predict clinical outcomes, according to a patent application."

So is this patent application, backed by tech's behemoth, a harbinger of the inevitable phase-out of doctors?

I don't think so. True enough: it’s almost certain that the role of computers in our practice of medicine will continue to increase. But the truth is that doctors' core role is so much more essential and irreplaceable than any diagnosis, computer-assisted or otherwise. Ultimately, physicians are healers. And a computer can diagnose. A computer can perhaps even treat. But it takes a human being to truly heal another. 

That said, I believe that for medicine to be truly resilient -- for healthcare providers to continue to be relevant into the future, we need to lean into the art and humanity of medicine. The trend over the last couple of decades has been to reward providers who treat medicine like a complex factory -- the more efficiently and flawlessly you can move through the heap of patients, the more you are rewarded. But I believe that we are beginning to experience a shift. And into the future, simply being efficient and precise is not going to be our path forward. 

I believe that medical collaboration with our very human colleagues is a crucial part of leaning into that art and humanity. It's a tool that we can use to treat the whole patient, and do so with true thought. Our practice will likely be assisted by machine learning and artificial intelligence in the future. But if we're doing our jobs right, that assistance simply can't replace us. 

Moody’s Investors Service came out with their 2019 projections and predictions for nonprofit hospitals.

And unfortunately the summary is: things don’t look great.

Although I don’t put tons of confidence or stock in this type of projection, I do think that the report captures many of the challenges that nonprofit hospitals face.

Fierce Healthcare does a good job summarizing Moody’s report: Moody’s says that nonprofit hospitals are on an “unsustainable path” because of “soft revenue growth, weak inpatient volumes and single-digit reimbursement increases in the coming year.”

Other challenges in 2019 may include lower cashflow, an increase in bad debt, lower inpatient admissions, and pressures like nursing shortages and increasing wages.

So much of healthcare is conservative. We don’t change until we need to. And for many nonprofit hospitals, there has been a consistent tendency to maintain the status quo in an almost superstitious fashion — if I don’t change, then nothing will change around me.

Reports like this demonstrate that things are surely changing around us. Our only choice as healthcare providers, as hospital administrators, and as citizens is whether and how to act proactively so that the things that matter to our organizations and to ourselves can be supported and pursued.

Healthcare is changing around us -- for better and for worse. 2019 will bring new technologies, shifts in reimbursement, demographic changes, and developments in our own practice as healthcare providers. Our goal can't be to not change within that. Our goal has to be to change towards what we envision for ourselves and for our patients. And with the new year here already, I encourage all of us to take the opportunity to reflect on what that might look like this year.

Telemedicine is not a new technology.

In fact, we’ve been doing telemedicine for almost 20 years at ClickCare. As you may know, we started by pioneering in a School-Based Health program at local underserved elementary schools. That program used newer technology — including some digital cameras — but really, the success of it was related to the approach and openness of the providers, patients, and families involved.

Because the school nurses and the pediatricians were so oriented towards caring for their young patients as well and as holistically as possible, they were open to trying new approaches. As participants saw the success of the program, it became broader and more organizationally supported. And honestly, at no point was there any conversation around reimbursement or policy — it was just one more way they cared for their patients.

All of the providers that use iClickCare today approach it similarly. While telemedicine is increasingly common, it’s certainly not the default. And so providers or hospitals that incorporate the tool do so as a conscious choice. Reimbursement improves; political and organizational support expands; but through it all, providers carry on with the tools and approaches they think will help their patients the most.

I was interested to read a report in JAMA, however, and extended in Fierce Healthcare, looking at how telemedicine use is expanding (or, in some cases, not), and how reimbursement laws relate to these adoption phenomena. Parity laws demand that insurer reimbursement be the same for telemedicine-based care as for in-person care. These laws have been adopted in 64% of US states. In confluence with this, there was a significant uptick in telemedicine usage among primary care physicians between 2015 and 2017. For more rural areas, mental health services seemed to be higher usage than other specialities. While in urban areas, primary care telehealth was more common.

This is all in line with the expansion of both telemedicine and reimbursement that we’ve seen. Parity laws demand that insurer reimbursement be the same for telemedicine-based care as for in-person care. That said, one interesting fact stood out: “the data showed a negative association with states that enacted comprehensive parity laws mandating reimbursement for the services.”  Perhaps that is because those states struggled the most with adoption in the first place — but either way, it’s clear that adoption “from the grassroots” may be more effective than approaches that aim to implement telemedicine starting at the policy level.

With any shift in practice, there is always a combination of technological, personal, psychological, and societal factors that need to come together for the technology to be incorporated into use.

For instance, simply inventing the telephone doesn’t create a culture that calls your friends. A combination of phone lines, social change, and early adopters combine with the new invention to lead to a society that talks on the phone.

On the one hand, telemedicine is becoming increasingly widespread, generally. There is increasing consensus that telemedicine can contain costs, increase access, and cut healthcare provider burnout. It’s not surprising that so many providers, patients, and payers are incorporating the technology into how they “do medicine.”  On the other hand, telemedicine implementation isn’t a matter of policy or a “snap of the fingers.”

Ultimately, telemedicine adoption must come from providers and patients. There is no way to legislate or demand creative ways of caring for our patients.

Learn more about how to implement telemedicine in your organization, economically and quickly, with our Quick Guide to Hybrid Store-and-Forward Telemedicine: 

Last week, Fierce Healthcare reported that the Joint Commission has decided to table the Telehealth standards that, in May, they had originally announced were in the works.

The primary focus of the standards was the portion of telehealth where care is provided direct from, and to, the patient. As The Center for Telehealth and e-Health Law reports, attorney Nathaniel Lacktman of Foley & Lardner said the standards would have "forced Joint Commission-accredited hospitals to obtain informed consent from patients prior to delivering care via telehealth. In addition, providers would have had to discuss with patients the 'type of modality that will be used' before providing care."As readers of this blog well know, iClickCare is all about using technology to help providers collaborate. This collaboration results in the best care for the patient, and the patient can be invited to join when desired and necessary. See our answer from our FAQs “Can I include my patient of family members in iClickCare?"

We're largely appreciative of the Joint Commission's dropping the standards. It's not that telehealth standards of any kind are out of the question. But the Joint Commission's proposed standards were troublesome because they were simultaneously narrow and too restrictive.

We believe that the portion of telehealth that is direct-to-patient is over emphasized in the telemedicine landscape. It's a tool with specific applications and potential because it doesn't allow a team of thoughtful providers to partner with a patient in asking the right questions about their own care. Instead, a "fix" is sought, and via technology, seemingly obtained.

As an architect friend of ours said recently, “Sometimes we come to a conclusion before we have defined the problem”.  We all know that the patients who often get the worst care are physicians and nurses.  Why?  Because they make the diagnosis, and seek the treatment from an ultra-specialist, before the big picture is analyzed. They seek the tree and miss the forest. Similarly, direct-to-patient telehealth can risk the same challenges. 

None of this has been addressed fully. Narrow standards applied to a isolated topic will do little to advance a broader view of technology and health and worse, stifle innovation and adoption.

One of ClickCare’s founders is a pediatrician.

And as a pediatrician, she’s no stranger to the obsession that new parents have over their babies.

Sometimes in her practice, it seemed that the more educated or well-off a parent, the more bizarre their parenting approach would be. Now called “helicopter parenting,” the excessive hovering and worrying that many parents show is nothing new.

A recent article showed that technology can certainly exacerbate a natural tendency, however. The New York Times looks at extreme baby monitoring gadgets. Whether it’s a sock that measures oxygen levels or a temperature indicator to tell you if your baby’s blanket has slipped, there are more gadgets than ever to allow parents to track babies continuously, night and day.

These devices are likely unnecessary and even potentially harmful in terms of the family dynamic. Dr. Michael Yaker of Westside Pediatrics in Manhattan and the Icahn School of Medicine at Mount Sinai says, “In general, do the vital signs of healthy babies need to be monitored regularly? Absolutely not… If your baby needs to be on a monitor regularly tracking vital signs, your baby is likely not ready to be discharged from the hospital.”

The article asks the valuable question: can this information be applied in a meaningful way, or is it noise? Is the information gathered from these monitors a) accurate and b) actionable? 

Similarly, the telehealth monitoring boom has meant that the most publicized and well-funded projects in the telehealth space are those that gather a lot of information using hardware devices. The allure of 24/7 data gathering and always-accessible videoconferencing is seemingly hard to resist.

In either, the case of excessive focus on telehealth monitoring or the case of the extreme baby monitoring, I believe that there is a dynamic in which fear is being capitalized on to sell quick fixes. Rather than asking what is truly good for the baby and the family, the monitoring is providing a few moments of salve for panic and worry. Similarly, expensive telehealth monitoring programs sound impressive but may not ultimately improve outcomes significantly or take the whole patient into account. Telehealth monitoring in conjunction with videoconferencing isn't really taking the whole system into account, either. If they were, they would be thoughtful about allowing asynchronous consults. They would enable medical collaboration. They would facilitate real human medical providers talking with each other about patients. They would engage providers in considering the whole picture, rather than just a few data points.

Ultimately, we believe that medical collaboration, enabled by an inexpensive and asynchronous tool like Hybrid Store-and-Forward® telemedicine, is the best tool available to truly improve medicine. We believe it's good medicine to be skeptical about whether gathering more data is always best: is it accurate? is it actionable? is it meaningful?

Last week Elon Musk announced a new plan for getting people to Mars — and a clearer idea of how SpaceX would make money at it.

As the New York Times reports, “The key is a new rocket — smaller than the one he described at a conference in Mexico last year but still bigger than anything ever launched — and a new spaceship.”

But it was a specific aspect of his vision that reminded me of the potential, promise, and reality of telehealth…

Mr. Musk’s Mars vision is interesting and almost unbelievable. (And, indeed, may not be practical, but time will tell.) “For Mars colonists, the rocket would lift a spaceship with 40 cabins, and with two to three people per cabin, it would carry about 100 people per flight. After launching, the B.F.R. booster would return to the launching pad; the spaceship would continue to orbit, where it would refill its tanks of methane and oxygen propellant before embarking on the monthslong journey to Mars.”

What is even more fascinating to me, however, is Mr. Musk’s vision for using the reusable rocket here on earth.

Because the rockets are reusable and because they travel up to 18,000 miles per hour, the rockets could take off to the atmosphere, and then come down in, say, Shanghai. Any two points on earth would be less than an hour apart. And, in fact, he says that the cost of a ticket would be cheaper than an economy ticket on a plane today. (He didn’t mention the leg room, but I’ll assume it’s better!)

When you watch the BFR “Earth to Earth” video, imagining the idea that you could get to Shanghai in 39 minutes, or from New York to Paris in 30, you start to wonder how our world would change if we could connect to each other so easily, so quickly. You think about how our understanding and empathy of other cultures might grow. You think about how new ways of practicing business, medicine, and art might emerge. How we might work and live differently, better. And you wonder -- if I could go to any country in the world before lunchtime, what would I do with that ability to connect? If I had the power to connect across the world, how would I use it?

The truth, of course, is that you have that power now.

Mr. Musk’s vision is big, and it’s encouraging to know that entrepreneurs with big visions are working towards new futures. But the truth is that in the palm of our hands, we have tiny computers that let us collaborate with medical colleagues in any corner of the world, even in a HIPAA-safe way, for a cost that is tiny. The reality is that telehealth now allows us to connect with patients and people across the spectrum of care in ways we couldn’t, even 20 years ago.

What will you do with that power?

Photo by NASA on Unsplash