Lower Wait Times Through Computer Aided Healthcare

A mentor of mine once told me that while living in Los Angeles in the mid-1980’s a “quick” run to the bank for cash withdrawals or to move money between accounts could take up to two hours, between the traffic and long lines.  The wait time pre-ATM proliferation was equivalent to a quarter of a work day.  Today, a cash withdrawal takes minutes and money transfers can be done online.  Technology and significant workflow changes revolutionized retail banking. Healthcare and its long line problem is currently in possession of technology that can shorten the que, lower costs of delivering care, and place the consumer’s (patient) needs/wants front and center.

Much like retail banking in L.A. thirty years ago, patients today face a long line problem in multiple specialties within healthcare, due in part to physician shortages.  In 2014, a patient in Boston waited nearly two and a half months to see a dermatologist.  A woman in Portland, Oregon had to schedule five weeks in advance to see an OB/GYN, and in New York City it took nearly four full weeks to get into a family practitioner[1].

Economics tells us that a que for a good or service means that price, for one reason or another, has not changed enough to drive equilibrium where demand matches supply.  Much like access to money, access to healthcare is fairly inelastic[2].  The growth in concierge medicine in recent years provides supporting evidence, as many consumers opt out of the que by paying for access where they can[3].  Given that nearly one out of two adults in America are afflicted with a chronic illness, concierge medicine practices alone will not be enough to lessen wait times and efficiently allocate our country’s healthcare resources.

Telemedicine in numerous forms and applications is alleviating wait times while lowering the cost of delivering care.  Just this past Thanksgiving, I was struck with a touch of the stomach flu.  Dehydrated and in need of medical advice, I skipped the hours of wait time and the expense of an urgent care or emergency department visit—since my doctor’s office was closed[4]—and ordered up a consult on my iPhone via an app.  I took my hours of wait time down to fifteen minutes and freed up emergency department staff to treat true medical emergencies.  Total cost billed? Fifty dollars.[5]  

Telemedicine in its multiple forms is in the early innings of driving productivity in much the same way the ATM did in banking.  The more interesting applications for telemedicine rest far beyond primary care providers.

With more than a third of all Americans, or 117 million adults, suffering from heart diseases, renal failure, cancer, diabetes, and other chronic illnesses, healthcare needs reach far beyond the medical offerings of primary care physicians and emergency departments.  Millions of these patients will need to be hospitalized, and some will find their way into intensive care units (“ICUs”).  In fact, ICU visits make up nearly 27% of hospitalizations, treating between four and six million patients a year, spread across the country’s 6,500 plus ICUs. To care for five million or more ICU patients in a year, the average ICU staffs less than two intensivists to treat patients who require high levels of around the clock care.  The situation is far worse for some ICUs that are unable to recruit intensivists at all to their facilities due to patient volumes, cost issues, and geography. For the better part of two decades, telemedicine has offered a solution.

Tele-ICU, also referred to as eICU[6], allows renting out intensivists and a team of critical care nurses to multiple hospitals at once.  Advanced ICU Care is the largest provider of eICU services, serving more than 60 hospitals across 26 states.  Their market share reflects being an early adopter that is broadly viewed in the industry as part pioneer and part tele-ICU evangelist.  Much like other direct to provider versions of telemedicine, Advanced ICU Care has to specialize in physician recruitment, licensing and credentialing, and IT implementation. However, that generally is where comparison ends to other acute care telemedicine services provided to hospitals, such as tele-neurology and tele-psychiatry. 

The ICU is filled with the highest acuity patients.  An ICU patient, on average, is touched by the bedside medical staff 178 times a day, which is one of the reasons why the cost of an ICU stay is nearly 2.5 times that of other hospital admits.  One intensivist might monitor between five times and twenty times the number of patients in an eICU compared to the ten or so they cover in a traditional bed side setting.  Triaging ten patients verses 50 or 200 patients requires a different approach that partners the intensivist with a machine.  The Philips[7] software that powers much of the eICU systems in place today is the true force multiplier of the intensivist, aiding in triaging patients and providing for early intervention.  The result of pairing physicians and nurses with machine is a 23% average reduction in the average length of stay for hospitals with an eICU solution, not to mention other superior patient outcomes, such as lower mortality rates. 

The excitement, fanfare, and bulk of the media coverage[8] of direct to consumer telemedicine focuses on the savings to the healthcare system by keeping patients out of the emergency department (“ED”) and urgent care centers.  Other direct to provider telemedicine services, such as tele-neurology produce value to hospitals in much the same way, by accelerating the throughput in emergency departments and freeing up much sought after beds, not to mention improving the quality of care delivered to the patients.  Through these examples, it is clear that telemedicine is recalibrating our healthcare ques by meeting the need of patients when and where it is needed most.

For many, the illusive holy grail in healthcare delivery is preventative care[9].  With 117 million patients suffering from chronic illness[10], our healthcare system routinely and regularly fails in delivering preventative care.  As a derivative of having a treatment focused system, physicians and patients have long been accustomed to computer driven reminders to renew a prescription.  Telemedicine and computer aided monitoring present new opportunities to manage the sickest populations before needing higher acuity levels of care.  By using applications and approaches developed for the eICU patient ques can be lowered without increasing the supply of skilled clinical labor which takes years to do.  An algorithmic approach to triage and patient care can make this possible.

With preventative care proving too illusive, many would settle for more effective population management tools to effectively stratify patients by need and treatment and drive improved outcomes.  Luckily, we can skip the sci-fi like day dream, imagining such broad population based monitoring and care by looking to Banner Health.  Banner Health[11] worked in partnership with Philips[12] to better monitor and deliver care beyond the hospital setting by providing a segment of their sickest outpatients with remote monitoring devices.  Oxygen saturation, blood glucose levels, blood pressure, weight, temperature, and other vitals are all remotely monitored, tracked, and triaged through a customized set of algorithms that empower the Banner telemedicine team to detect issues earlier before becoming possibly more severe health episodes and provide interventions, using a combination of social workers, nurses, and physicians.  Just like in the case of eICUs, humans are the tip of the spear, delivering care with the help of technology.  Also like the eICU, the staffing ratios of healthcare professional to patient are superior to more traditional in-person settings.  The results, after a year of operation, included a 27% decrease in cost of care delivered to the covered patient population, along with reducing hospitalizations by nearly half[13], [14].

Splash 4’s highlighting of a program leveraging remote monitoring, digital health algorithms, and telemedicine is far from a sycophantic infatuation with technology and buzzwords.  Rather, it reflects an appreciation for a disciplined approach to process innovation in the healthcare space.  One need to look no further than the shortcomings of promises following wide scale adoption of electronic medical records (“EMRs”) to see how technology acquisition alone is insufficient and often a costly disappointment compared to expectations.  After all, technology acquisition and implementation is the easy part (though, try telling that to anyone experiencing it), introducing humans to a new process is where the real challenge begins.

In healthcare organizations, the status quo rules supreme.  The disruption of old rules, stemming from the Affordable Care Act, has placed new incentives in the market for many organizations to pilot new approaches.  Given that nearly 20% of GDP is tied to healthcare, the reward for those who find success is clear.  However, few for-profit or non-profit entities do innovation in healthcare well.  In part because the pain associated with change and the liability associated with deviating from industry norms[15].  Numerous examples could be noted here listing the failed commercialization efforts by hospitals in telemedicine alone.  It is for that reason, we highlight Banner’s positive deviation from the norm.

What has driven Banner’s positive deviance?  As with most successes, the mechanics of success derive from multiple sources.  From afar, here is a non-exhaustive list of those factors:

1)     Systemized Success:  Banner conquered and found repeated success in one of the most dynamic and challenging applications of acute care telemedicine—tele-ICU.  By conquering something complex and developing strong process and procedures around it allows for thoughtful and appropriately resourced organizations to apply the knowledge to new use cases and departments.

2)     Focus & Specialization: Banner applied a managed discipline around what telemedicine programs their hospital system will own and manage and what they will outsource.  This style of discipline allows for prioritization and for an efficacious allocation of resources in terms of staff, money, attention, and time.  By not sourcing all telemedicine solutions in-house, the system was freed up to explore a telemedicine approach to managing population health.

3)     Organizational Patience: Banner practiced organizational patience.  Often with technology adoption, individuals think taking the IT out of the box is enough to drive the desired result.  Yet, I know many people that never lost a pound or bested a mile time that wear a Fitbit. Telemedicine solutions are no different; only, they involve a greater number of people and far greater dollars.  Adopting a new telemedicine solution is really a behavioral change in the delivery of care; technology just happens to be involved.  This takes time, investment, oversight, and significant testing of outcomes.  The organization and its top brass must accept that failure is possible but resource their team for success.  S4P has examined numerous examples where organizations pull support due to a lack of patience that is derived from shifting priorities and the lack of a stomach for waiting for profitable results. From our point of view, this is the organizational equivalent of tossing that Fitbit in a drawl, frustrated by a lack of results without making changes to one’s diet and exercise routine.

4)     Consistent Coaching: For any telemedicine program to work, clinicians in management roles must actively coach other clinical staff.  Again, telemedicine changes the behavior of how clinicians deliver care and how patients receive care.  Without coaching clinical staff to the short-term challenges of altering their delivery of care, these programs fail.

5)     Leadership & Accountability: While Splash 4 Partners does not know this for a fact, we surmise Banner had strong program leadership and buy-in from the senior executive and clinical teams.  This initiative was made an institutional priority, and the project leaders on down through the ranks were likely given appropriate authority to “make things happen.”  People supporting the effort were held accountable for outcomes, and part of that means those who were not supportive of the efforts and were creating roadblocks were not tolerated and similarly were held accountable, by being removed as roadblocks.  For any telemedicine program to be a success, strong leadership and accountability are critical. 

ATM adoption, while likely simpler in many regards, relied on these five success factors to drive adoption.  The result of this marriage between human capital and machine in finance resulted in a growth of retail branches and jobs in the sector.  As the digital landscape encroaches and incorporates itself even more in healthcare, the salience of these lessons become ever more important.  Telemedicine programs and algorithmic managed care offer great promises to lessen the points of friction that drive up the cost of care or elongate the wait times for care.  To better allocate the scarce healthcare resources as the population ages and 117 million Americans and counting struggle with chronic illness, physicians and nurses will have to collaborate with machines more often.  Irrespective of political administration, the challenge that lays before managing clinicians and hospital administrators is one to manage the struggles and strife associated with changing the behaviors and workflows of their staff as healthcare embraces technology as consumer finance did more than three decades ago.

 

[1] http://www.nytimes.com/interactive/2014/07/06/sunday-review/waiting-and-waiting.html

[2] Please note, this piece does not directly or indirectly take a position of universal coverage.  Rather it reflects the state of the American healthcare system based upon facts and real world cases.  The lens Splash 4 Partners used when writing this piece is one of resource optimization. Many reasons exist for ques and for price being a poor signal in the healthcare industry.  Better resource allocation within healthcare benefits all, regardless of one’s view on what the best regulatory stance and polices are for healthcare.  

[3] From Splash 4 Partner’s (S4P) perspective, healthy growth in this area will likely continue due to physician burnout driven by seeing 20 and 30 patients a day in non-pay for access primary care practices. 

[4] One of the leading primary care telehealth companies reports that more than a third of its tele-consults occur on weekends and holidays and approximately 50% of visits occur outside of business hours (source: Teladoc S-1).

[5] Truth be told, I had to use two different apps to get a similar standard of care to a bedside experience.

[6] eICU is technically branded but colloquially used to address the use of telemedicine in ICUs, much like Kleenex or Xerox for tissues and copying.

[7] Visicu is the company/software that powers most eICU platforms today.  It was spun out of Johns Hopkins and eventually sold to Philips who owns and manages the company today.

[8] The media coverage in recent years on direct to consumertelemedicine apps is as much about the press filling column inches and airtime as it is about Doctors on Demand, Teladoc, and others advertising to potential customers.

[9] Some physicians and public health experts believe that preventative care is a form of selection bias and non-scalable.  A strong argument for this is tied to the fact that behavioral changes are difficult and often need individualized coaching, or other forms of support to alter behavioral patterns that negatively impact health.  For those demonstrative use cases where preventative care has “worked”, some argue that the causal mechanism is not treatment but rather a well warn path of good behaviors, or purchasing of services that alters and reinforces the desired behaviors.

[10] https://www.cdc.gov/chronicdisease/overview/

[11] Note that Splash 4 Partners has no official relationship with Banner Health.  Information presented related to their telemed efforts are based on public resources and a handful of conversations with industry participants familiar with the operational structure of the systems efforts.  S4P views are informed by these conversations and having evaluated a number of telemedicine companies.   

[12] Think of this as NCR or Diebold working with JP Morgan or Bank of America in the 1980’s or 1990’s to improve the customer experience via ATMs.

[13] Splash 4 Partners Primary Research

[14] http://www.fiercehealthcare.com/it/population-health-lessons-from-banner-health-s-telemedicine-program

[15] Innovation is hard in part due to the natural proclivity of humans.  Those that do innovation in healthcare well are truly abnormal, as the average human is driven by loss avoidance. 

Jacob Grosshandler