Here’s What Your Future Doctor Visits Could Look Like

By Ray Dorsey & Eric Topol |  May 2, 2017  |   Fortune

Today’s office visit to a doctor involves a patient, a family member, and a physician 97% of the time. Tomorrow’s visit will engage nurse practitioners, nutritionists, genetic counselors, pharmacists, therapists, social workers, mental health professionals, and exercise coaches. The Internet enables clinicians to connect patients at different times based on need, not travel burden. Just as more clinicians will contact patients, more caregivers including children living in different cities and countries will participate remotely in visits through video conferencing.

The nature of visits will also change. Patient-generated data creates the opportunity for the visit to be a true data exchange. Tomorrow’s visit will include objective, high frequency and real-time streaming data, including blood pressure, glucose levels, activity levels, diet, and social engagement metrics. Patients will control the data from novel sensors and grant clinicians access at the patients’ direction.

As many visits will be remote, the physical exam will approach a medical selfie. Smartphone attachments, some of which are already cleared by the FDA, will help perform the physical exam, including taking vital signs, listening to heart sounds, and visualizing ear drums with greater clarity that will enable clinicians and patients to see what was previously invisible to them.

Tomorrow’s office visit will be separated by time and space. Asynchronous health communications (e.g., text) will increase. Patients will update their health and pose questions, and clinicians will provide responses and educational content in reply. Synchronous video visits will be a 24/7 service. As the need for clinics diminishes, the ability to deliver evening, night, and weekend consultations will increase. Kaiser Permanente of Northern California now has more email (separated by time), phone, and video (separated by space) visits than traditional office visits.

Tomorrow’s office visit will increasingly take place everywhere but the office. Telehealth and the house call will become increasingly common. Health care, like other services (e.g., retail), will move from institutions to satellite clinics, homes, and mobile devices and make medical care as convenient as shopping. In-person care will also increasingly be delivered directly into the home. Nurses have long visited the home, but physician house calls, which accounted for 40% of medical encounters in the 1930’s, are returning. These patient-centered visits range from a hospital at home model to smartphone applications that enable individuals to find a physician for a house call just as they find a driver for a ride. The change in travel direction (doctors coming to patients) symbolizes the power of patients to drive their care.

The substantial shortcomings of current office visits are triggering these changes. Today’s 20-minute or shorter doctor visit takes 2.6 weeks on average to schedule and requires two hours of travel and waiting. While most patients like their doctor, almost no one likes going to the doctor. By contrast, tomorrow’s office visit will offer patients unprecedented access to confidential, expert care that is delivered conveniently in the comfort of their homes.

The future office visit will require change. That change will initially come from outside medical establishments whose processes, policies, and economics are tied to today’s outdated models. Fueled by technological advances and financial investments, new entrants will re-shape care delivery. The timing of tomorrow’s visit will depend on policies changes that currently incent institution-centered care and hinder patient-centered care. That said, social forces, including the mobility of the nuclear family, the aging of populations, and the rapid adoption of technology will drive the expanded use of telemedicine visits.

These changes will have profound implications for medical centers, the profession, and patients. For medical centers, the physical and labor needs will change as demand for clinic space, waiting rooms, and parking lots will eventually decrease. For clinicians, providing care in the home will require more training to move out of hospitals. The patient-physician relationship will also change. Patients will have access to and utilize more clinicians, including experts whose geographical reach will expand. Visits may be more frequent, shorter, and remote. Local physicians will foster longitudinal relationships, ensure care is coordinated, and deliver services (e.g., procedures) that cannot be done in the home or remotely. Finally, patients will exert more control over their care and shape the future through their advocacy to receive care (largely funded by their labor and tax dollars) on their terms.

In 2001, the Institute of Medicine wrote, “Between the health care that we now have and the health care we could have lies not just a gap, but a chasm.” Technology has pushed the frontiers of the possible. Now is the time to realize these new possibilities.

Ray Dorsey is a neurologist and director of the Center for Health and Technology at the University of Rochester who cares for individuals with Parkinson disease over the Internet. Eric Topol is a cardiologist, founder and director of Scripps Translational Science Institute, and the author of the books, The Creative Destruction of Medicine and The Patient Will See You Now.

Penn Medicine is launching an mHealth project on the ResearchKit platform, aimed at connecting healthcare providers with the few thousand people across the globe who have a rare condition called sarcoidosis.

An inflammatory condition that leads to the formation of lumps known as granulomas, sarcoidosis usually begins in the lungs, skin or lymph nodes, but can affect any organ, including the brain, heart, eyes and liver. The largest study to date on the disease enrolled some 800 patients for three years and involved 20 health systems across the country.

Misha Rosenbach, MD, an assistant professor of dermatology in the Perelman School of Medicine at the University of Pennsylvania and one of the leaders of the ResearchKit study, said the previous project didn’t answer critical questions about the disease. He’s hoping a study that connects researchers in real-time with patients through their mobile devices can produce better data.

This new app has the potential to build up a larger cohort of more diverse patients in a shorter amount of time,” he said in a press release issued by Penn Medicine. “There’s a motivated and engaged group of sarcoidosis patients who are active online, but there’s a whole host of them out there we don’t know about. This app, which can securely, privately, and anonymously collect data, casts a wide net that may engage those people, and funnel valuable, much-needed information to researchers.”

This latest study is a timely bit of news for Apple’s clinician-facing mHealth platform, which is starting to see a host of challengers interested in the growing clinical trial space. It also marks an evolution of sorts for ResearchKit:  while many of the studies unveiled in the two years since the platform was launched have focused on large populations, chronic conditions or public health issues, Penn Medicine is looking to target a much smaller population whose members are scattered across the globe and not easily gathered together.

“There’s a great opportunity that has never been done,” said Rosenbach, who’s collaborating on the project with Daniel O’Connor, a fourth-year Penn medical student, and Marc Judson, MD, of Albany Medical College and the Foundation for Sarcoidosis Research. “In traditional research, you can’t see patients every day, but in app-based research you can suddenly get all this information about the disease in real-time and over time, from many different patients all over the world. It gives us the power to do sarcoidosis research in a way that has never been done.”

Patients opting into the study will provide researchers with information about the disease, including how often it flares up, how it affects their lives and what medications are used. In addition, the study will collect data from each user’s iPhone, including lifestyle markers like activity and weather conditions. Finally, patients will be supplied with educational resources, links to information and advocacy groups, and directions to the nearest specialists based on their GPS coordinates.

That back-and-forth between patients and researchers is another evolution of the platform. It’s also seen in the Stanford University School of Medicine’s recent release of MyHeart Counts 2.0, an updated version of the ResearchKit app that adds precision medicine to the research project focusing on heart health.

“We know when it comes to changing key health habits, such as physical activity and daily sitting time, one size definitely does not fit all,” Abby King, PhD, a professor of medicine and health research and policy at Stanford, said in a news release prepared by the university. “Yet until the advent of mobile apps and other e-health programs, we’ve had few options for customizing messages and feedback to individuals in real time.”

Rosenbach and his team are hoping that information collected from patients will help them understand a condition whose cause hasn’t been determined. Researchers have found that it’s apparently triggered by the body’s response to some foreign material, such as an atypical infection, but doesn’t stop when the infection goes away, and continues to produce granulomas that can lead to organ damage.

O’Connor told Penn Medicine News he’s hoping the study can someday be modified to target other rare diseases.

“We’re excited about future opportunities to repurpose the app for other rare diseases as well,” he said. “With a strong app framework in place, sarcoidosis could be swapped out for another disease, allowing wide networks of patients all over the country to participate in Penn studies without traveling to Philadelphia.”

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