Early this year, Stephen Parodi, MD, a Kaiser Permanente administrator and infectious disease specialist who does part-time clinical work, saw a longtime HIV patient at the Kaiser Medical Center in Vallejo, California. The patient had been taking antiretroviral drugs for many years, keeping the virus in check, when he showed up at the clinic with a skin rash. Parodi, who has been treating the man for 16 years, wanted to be sure his patient didn’t have a serious complication called Kaposi’s sarcoma.
“In the past, you might have said, ‘Okay, you need to see a dermatologist. I’m going to put in a referral, and you’ll hear back from the clinic, and you’ll get an appointment sometime,’” Parodi said. Weeks or months of uncertainty might follow.
But this time, Parodi had a new way to handle it. He took a picture of the patient’s rash with a smartphone equipped with optical software that enabled him to capture a detailed, high-quality image. While the patient was still in Parodi’s exam room, he sent the image to a Kaiser dermatologist who quickly replied.
One and Done
“He texted me back and said: ‘I think you can treat this with a cream and then let me know in a couple of weeks if the rash is not better,’” Parodi said. He also suggested that Parodi order a biopsy. After a single office visit, the patient left with a treatment plan.
The encounter illustrates the early stages of a shift in the way many health care systems operate as they embrace new technologies to better organize care delivery and address the worsening shortage of physicians.
With its strong focus on primary care, Kaiser has been a pioneer. The health system operates in eight regions of the US and has 11.8 million members. Fifteen years ago, it began to use call centers staffed by nurses and overseen by emergency physicians to make appointments and handle basic information requests. The aim was to help patients avoid a trip to a medical center or clinic.
Rather than you having to navigate all the different specialists, this team does it for you… This is good for the patient because it’s less confusing. — Stephen Parodi
During the 2018 flu season, the Northern California regional call center handled up to 45,000 calls a week related to cold and flu symptoms and addressed most of the issues by phone. “Imagine if we didn’t have that in place,” said Parodi, a 16-year Kaiser veteran who is associate executive director of the Permanente Medical Group. “The only place people would have been able to access care would have been direct office visits, which would have been overwhelming.”
Kaiser also has developed a system where members can send secure messages to their primary care doctors, who are expected to respond within two days. Although patients are advised not to send messages with urgent health matters, Kaiser medical assistants scan the emails for issues requiring prompt attention. Kaiser information technology engineers are exploring ways to have computers take over this task.
New Routine for Routine Matters
MedStar Health, a nonprofit health system serving 300,000 patients in and around Washington DC, launched a similar system earlier this year that lets patients email their primary care physicians. The idea is to help them get answers or action on routine matters — a prescription refill, for example, or a question about side effects of a new medication — and reduce the need to come in.
The message is seen first by a care navigator, who forwards it to staff members with more training or experience as needed. “You only pass to the next level when it’s necessary,” said William Sheahan, PhD, MPH, a vice president and director of MedStar’s Telehealth Innovation Center. This approach helps ensure that a scarce resource — the time of nurses and doctors who have advanced training — is optimally used for the care of patients with the most complex needs.
In the coming year, MedStar also plans to begin testing a text-messaging system. Patients would be able to use a smartphone app to send a text about an urgent care need. The message would be routed to emergency doctors in a telemedicine-enabled triage unit. They could reply to the patient by text, by phone, or with a video teleconference to, for instance, look at a rash.
“In a matter of 15 or 20 seconds, you could get to an emergency physician who would help you decide what to do,” Sheahan said. Handling this communication by text message is appealing, he said, because it’s the communication method that’s “the easiest, most likely to be used.”
Scanning Medical Records to Make Predictions
An even higher level of technology is being harnessed at the front end of a new Kaiser effort called Care-Plus to help primary care physicians focus and organize services for patients with complex needs. The idea is to assess a patient’s conditions, medical history, and lab tests by focusing predictive analytics on his or her electronic health record.
Social workers compile information on patient’s behavioral health issues, access to transportation and food, and even neighborhood based on ZIP code. All the information gets plugged into a computer algorithm developed by Kaiser researchers to set a risk score and estimate the likelihood that the patient will need more and different types of health care. A multidisciplinary care team consisting of a primary care physician, a nurse care manager, and a program coordinator review the risk score and work with the patient to develop a treatment plan. The team works with various medical specialists to set up consults, tests, and follow-up appointments so the patient doesn’t have to negotiate the complex health system on his or her own.
“It’s our job to do all the behind-the-scenes work,” Parodi said. “If you have diabetes and heart failure, and maybe a third condition, rather than having to navigate all the different specialists, this team does it for you. This is good for the patient because it’s less confusing.”
The goal of all this technology is to “leverage the existing workforce to take care of the ever increasing numbers of patients,” Parodi said. While Kaiser’s size and resources enable it to pursue technology-driven innovations, smaller organizations can also look for ways to use technology and good planning to identify a patient’s needs as early as possible. The idea is to apply what Parodi calls “the principles of prevention: Any time you can take care of an active disease process earlier in the course and prevent complications, that’s better for the patient and the health care system.”
Telehealth Lets Patients Avoid Long Waits for Appointments
One way to achieve that goal is to bring consultations with specialists into the primary care doctor’s office, said Thomas Nesbitt, MD, MPH, an emeritus professor of medicine who helped pioneer the development of telehealth services as an associate vice chancellor at UC Davis Health. If a person with diabetes needs to change their insulin dosage, the primary care doctor can consult by video with an endocrinologist, saving time for the patient and for other nurses, doctors, and staff members. In regions with few specialists, using telehealth allows the patient to avoid months-long waits for an appointment.
It’s also more efficient for providers. With video consults, the primary care doctor can quickly introduce a patient to a specialist, Nesbitt said. “You come online, and you say, ‘This is Mrs. Johnson, a 57-year-old woman I’d like to introduce you to. She’s been diabetic for 16 years, has been on oral medication. My question is: ‘Should we switch her to insulin today and, if so, at what dosage?’”
While this approach helps address the acute shortage of specialists, it also shifts work from specialists to primary care physicians, who are also in short supply. The primary care office becomes responsible for answering follow-up questions, issuing prescriptions, and educating patients about managing medication.
This approach, when done well, saves time and improves care, in part by reducing the “churning” of patients who otherwise may return again and again for an unresolved issue, Nesbitt said. “Initially you put additional work on the primary care physician,” he said. “But if they can get to the right answer quicker, they may not need so many follow-ups.”
Good technology is important, said Sheahan, but so it structuring care systems so patients are interacting with the most appropriate providers. The goal is for every clinician on a health care team to work “at the top of their license,” providing services they are uniquely qualified to deliver while other staff members handle such things as renewing medications or answering basic questions.
“We want to get the right patient the right contact, at the right time,” Sheahan said.
Rob Waters is an award-winning health and science writer whose articles have appeared in BusinessWeek, Mother Jones, STAT, San Francisco magazine, the San Francisco Chronicle Sunday magazine, the Los Angeles Times, and many other publications. He lives in Berkeley.