Visit Based Medicine or Technology Engagements?
Written by Editor   
Friday, May 08, 2015 12:00 AM

The new way of practicing medicine will involve fewer office visits and more between-visit engagement with patients.  With a shortage of primary care physicians, an aging population, and an epidemic of chronic disease, "this [visit-based system] is a huge imbalance."

The problem with visit-based medicine is that it's hard to figure out what the right interval is for seeing patients. "If I see you once a year, I can examine you ... and draw conclusions about what's going on with you based on that one visit. Maybe I could do it two times a year ... but we could get closer to reality if we did not think 'episodic' but instead did more representative sampling."  And those types of short, infrequent visits also aren't good for engaging patients. "Think about what happens: you're there for a 15-minute visit with your healthcare provider. You agree with [the care plan]. And what happens is you leave the office and you sort of forget.  There's no reminding, no touching base. It's hard to maintain behaviors and get people to agree to a commonly agreed-to plan unless there is some sort of engagement between visits.

If we're really going to manage people's health and not just focus on 'epistrophic' care, we really need to think about health, which is what happens outside and between visits.  A better idea would be to space the visits out a little more, establish some health literacy, and monitor patients' clinical progress -- blood sugar control, pain, blood pressure -- between visits, and set and track personal goals.  The between-visit system will need to include some automated personalized outreach, and "we need to think about workflow."  "We always think about the healthcare provider's workflow, but we need to think about patients' workflow as well."

When asked about whether there were any health security issues with patients sending in the clinical information. He responded that there were not, because "there is no free text; people are not going to be typing in that in addition to their blood pressure being 162/90, they're also suicidal. We avoided [free text] for exactly that reason."

He also noted that from a legal standpoint, asking for the data only in certain frequencies was not a problem. "Are they going to be sued because they didn't ask every 2 weeks instead of every 4? No, because the standard of care is not to ask at all," he said. "The standard of care is not to care."

Another questioner said that although this kind of hands-on engagement might work in a practice with a small panel size, it seemed less doable in a standard practice with a panel size of 800 to 1,000 patients per physician. The response was "75% to 90% of those patients coming through the door were brought back as a matter of routine, not a matter of need. How many patients could be supported in [this] way if you actually brought back [only] those that needed to be there? I guarantee you it's bigger than the current panel size."