The COVID-19 pandemic accelerated the transition from in-person care to virtual care, as office visits increasingly gave way to televisits and email exchanges. The transition, while helpful during lockdowns, means that physicians now juggle packed schedules with increased electronic documentation and overstuffed inboxes.
To address this workflow crisis and improve the patient-physician relationship, Stanford Medicine's Kevin Schulman, MD, and colleagues are proposing a new approach they call digitally enabled care (DEC) that they believe can ease clinical workload and improve services for patients beyond virtual visits. They lay out a comprehensive set of patient services they say technology enables in a new commentary in NEJM Catalyst: Innovations in Care Delivery.
"Across medicine, we are struggling to keep up with clinical demands," said Schulman, a professor of medicine and deputy director of the Clinical Excellence Research Center.
"Working here at Stanford, we see amazing AI technology being developed that can support patients and patient care," Schulman said. "It's exciting, but AI development is just a set of individual projects today. We wrote this paper because we felt there wasn't a coherent framework to envision potential applications of technology, and to advocate for appropriate payment models for digitally enabled care."
We asked Schulman, a health economist working at the intersection of business, medicine and technology, to identify key challenges to implementing digitally enabled care and how a DEC framework could advance patient care and improve physician workload.
First off, what is DEC?
The digitally enabled care framework that we are building encompasses three periods of the physician-patient encounter: pre-visit, visit and post-visit. Notably, the framework incorporates elements informed by behavioral science principles that would reduce patient stress and support patient preparation, engagement and health literacy.
In our paper, we describe the opportunity for an entirely new set of digital resources and services designed to support the patient's engagement with their care plan by outlining steps that both the clinicians and patients can take before, during and after their virtual or in-person visit.
The digital waiting room would be patient-specific with links to past visits and test results, electronic health records, check-up goals, or specialist referrals.
What happens once the physician and patient are connected for a telehealth visit?
The patient should be allowed to opt in to a recording of their conversation so they don't have to worry about taking notes or remembering everything. They could then play the video with their caregivers or family members. Emerging AI technologies can create transcripts and update the patient's chart, as well as prepare prescriptions for approval by the physician, reducing paperwork burdens and increasing time spent on patient connection. Screen sharing of the digital waiting room would allow the patient to view the physician's face while jointly viewing visual information such as test results and X-rays.
We've also taken on the common challenge of integrating care across providers, which is touted as best practice but often difficult to achieve. For example, a patient recovering from an accident might have a primary and an emergency care physician, but might subsequently need an orthopedic specialist, physical therapist or plastic surgeon. Within the DEC framework, interpractice information sharing and coordination is facilitated by the inclusion of an on-screen list of the patient's other physicians with linked contact information.
Would other devices, such as smartwatches and heart monitors, link to the framework?
With patient buy-in and proper use and architecture, the DEC visit can connect with these devices to better observe, diagnose and support patient health. Digital tools like smart mirrors and smartwatches -- which can track movement, blood oxygenation or heart rates -- can be linked to the patient portal by Bluetooth (or the electronic health record can be linked to a personal health record which could integrate the data at a patient level). Stationary bikes and treadmills are already providing cardiac information and activity levels -- even falls or other safety concerns -- and synching them would allow physicians to specify instructions and direct patients to different physicians or therapists, enabling more holistic care and resulting in fewer omissions.
How do you envision the framework benefiting post-visit and ongoing care?
One of the complaints we hear most from patients is that their hunger for post-visit services is largely overlooked. Their queries and requests pile up in clinician inboxes. But if done properly, effective patient visits should result in an action plan that includes behavior changes, medications, diagnostic tests or clinical referrals. The value of the visit is not only developing this action plan, but also helping patients implement visit goals, such as filling their prescription -- it's estimated that 20-30% of new prescriptions are not filled in a timely manner by the patient -- and taking the medications correctly.
We also discuss post-visit educational tools. Today, we give out uniform educational materials, almost always on paper. But everyone learns from video these days. Why shouldn't you leave a visit with educational information in your language, at your reading level, in video format?
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Another key component of the DEC framework is built on behavioral science literature that highlights the importance of habit building, such as brushing your teeth morning and night. The digital post-visit would allow physicians to deploy habit-building tools to facilitate new health habits based on the plan developed during the visit via emails, text messages, or other digital tools.
Why hasn't this type of framework already been built and implemented?
That's a great question! First, the AI technology to power all these applications is new. The public began engaging with high-fidelity large-language models a little more than a year ago. Second, we're all excited about technology innovation, but much of what we describe is business model innovation that has received much less discussion. We need these tools to help drive productivity gains, and that comes from changes in the underlying process of care. Finally, our payment models are a barrier. This is an important section of our paper and really requires a lot more discussion. Most of our current payment models are actually efforts to reduce demand for services, from co-payments in a fee-for-service world, to capitation payment models that shift provider incentives to limit care.
But AI can transform how we think about digital health care services -- we don't need to restrict access to digital tools and services since the marginal cost of providing an additional digital service to a patient is essentially zero. With these economics as a driver, we can liberally push out services, especially to those who are currently underserved. In the paper, we talk about how this might change the way we think about payment for medical services. Imagine if instead of the current model, we carved out 10% of health insurance premiums and used that money to provide a subscription to support digital and in-person primary care and preventive services. That dedicated funding model would rapidly create a robust marketplace for the DEC model.
Photo: DragonImages via Getty Images
