By far, the most expensive line item in any care delivery model is people. How many people does it take to deliver the best outcomes? This is often modeled via doctor-patient ratios. How many doctors can care for a defined population of patients? A traditional doctor working 240 days a year with 20 visits a day can do 4,800 visits a year. For a population with chronic conditions, this equates to 1,200 patients each getting 4 doctor visits per year.
The bottleneck is a doctor’s time. And there are two ways to increase a doctor’s throughput in traditional time slot care:
- Increase the number of time slots per year (make docs work more hours)
- Reduce the time of each slot (give patients less time with their doctor)
Beyond that, traditional care has attempted to reduce the workload of doctors by “extending” them. Traditional practices hire less expensive “physician extenders” like nurse practitioners or physician assistants to offload the less technical time slots and email messages. The work is the same (caring for patients via time slots and emails), but the cost is lower because “extenders” command somewhat lower salaries.
The technology powering a care model needs to significantly reduce the cost of delivering care compared to traditional models.
What are some ways technology can do this for a modern care model? By understanding the time sucks of a traditional care model and automating or offloading the largest time sucks for a care team. These are the “Big Four.”
Translating oral conversations into EMR data
Roughly 40% of a doctor’s time per week is spent documenting or, rather, translating an oral conversation into billing data, in their EMR. Traditional care has invented medical scribes to listen in on exam room conversations and document for doctors. The doctors must then spend time reading the documentation and correct any errors, reducing the efficiency of this concept. Other solutions, like Abridge, attempt to automate documentation, but are not widespread in traditional EMRs. A far more widespread means of automating documentation is the use of visit templates in EMRs so doctors can “templatize” visits. This has led to ~50% of EMR content being multiple pages of templated text per visit forcing doctors to spend expensive time wading through all of that content to attempt to ascertain what’s different from the previous visit.
Orally gathering a history
About 70% of a traditional time slot is spent asking the patient questions about their condition. What are your symptoms? When did they start? Have they gotten better or worse? What have you used to treat them? Traditional care models have offloaded this to paper on clipboards or online tools like Phreesia (an patient intake platform). Online tools are great for gathering a basic history but the magic is in the details of each patient’s unique situation, and the back and forth conversation that happens between doctors and patients.
Educating patients about their condition and the plan to treat it
About 20% of a traditional time slot is spent educating the patient about their condition and/or the plan to treat it. Traditional care models have outsourced this to paper handouts that often include generic “home instructions” that all patients get with this condition plus a few sentences specific to the patient that were manually typed in by the care team. The patient is then on their own to google. Research suggests patients forget 85% of the content of oral conversations with their doctors. Communicating the value of a treatment plan is, by far, the most important element of delivering care (in an outpatient setting, patients do all the work of the treatment plan) and the traditional method is only 15% effective. This stage of care delivery not only consumes expensive doctor time, it is massively error prone due to patient recall of the details.
Atomic element long tail work
If the above three components are how traditional doctors spend the majority of their day, the rest of their day is spent.
- Ordering tests, prescribing medications, etc
- Reviewing test results
- Interfacing with external specialists/facilities/entities
- Tracking progress
- Continuing standarized education
- Proactive ongoing clinical support and question answering
- Determining resolution or ongoing management
- Maintenance or prevention
I call these the atomic elements of care.
Now that we understand how doctors spend the majority of their working time, the question is how do we use technology to maximize their time while also:
- Retaining real human connection between doctors and patients
- Increasing their quality