Wednesday, November 16, 2005

Dr. Aniruddha Malpani writes: Leveraging Technology to Make Doctors More Productive

Everyone agrees that the healthcare industry in the US is a mess. This is a major multi-billion dollar opportunity and India can provide a solution , if we learn how to leverage technology intelligently to make our doctors more productive. Indian doctors are world- class; as is the Indian IT industry. If we marry these cleverly, we can significantly improve patient care all over the world. In the past, we helped to support healthcare in the US and the UK by exporting our doctors ( the "brain-drain"). We can now export our services instead.

Today, the major bottle neck for efficient healthcare delivery in the US are doctors. Doctors are few and far between, and are an expensive resource ( after all, it takes a lot of time and money to train a doctor) . How can we make better use of this scarce resource ?

Today, unfortunately, most of their time and energy is spent on paperwork (�documentation� ); and talking to insurance and HMO clerks for authorization. This creates a lose-lose situation. Doctors are unhappy and frustrated; and patients are angry because they perceive their doctors as being uncaring and rushed ; and are frustrated over the long waits for appointments. For example, it can take an infertile patient over 3 months to see a consultant in the UK today !

The solution I'd like to propose is the use of technology to leverage a doctor�s productivity. ( This would not apply for emergency situations, but for medical care for cold �elective� problems, such as fever, diarrhea, and chronic illnesses such as arthritis and asthma, which constitute about 90% of all medical care episodes.)

We need to change the model of the consultation � the entry point into the healthcare system. At present, a consultation is inefficient and time-consuming. Traditionally, this has been � face to face �, but this is an archaic model. It�s time for a makeover ! After all, communication technology has changed everything else � why not this too ? Businessmen conduct conferences and meetings efficiently online � why can�t doctors and patients ?

We need to replace the consultation with a better alternative ! I agree this may cause a certain degree of discomfort , because the visit to the doctor is still the �holy cow� of medicine, because medicine is based on �doctor patient contact �. However, is this really needed ? Isn�t there a better alternative ?

Telephone diagnosis is now routine for many specialties , and has been proven to be safe and effective. This confirms that options to the traditional real world consultation are viable alternatives we need to actively explore.

I am going to offer my solution based on my personal experience. As an infertility specialist, I am a resource in scare supply. It takes me about 60 min to do a consultation, and I can manage to do about 4 consultations a day . I am in private practice, and have a wait list of 2 weeks. It also takes the patient a total of 3 hours of their time ( to commute to the clinic and to wait for their turn) to come for a consultation. How can we make this more efficient ?

What do I do in a consult ? Primarily, like most specialists, I take a history; review the records; and then formulate a treatment plan. I don�t need to do a physical examination for the vast majority of patients. ( Many studies have shown that over 80% of medical diagnoses can be made based on the history !)

I have therefore designed a structured questionnaire on our website, which anyone anywhere in the world can fill up online and email to me . I can review it and reply by email and it takes me an average of about 5 minutes to reply to each query. I know what the key points on the form are; so that I can quickly look for these; and then guide them accordingly. Most problems are ones I have encountered before ( after all, I am an expert !); and most questions are ones I have answered before, which means I can reply much more efficiently

This is actually a better model than a face to face consultation ! In fact, a personal consultation may not be the most effective or efficient way of providing the doctor with medical information ! I know this may be iconoclastic, but patients are often confused, disorganized, or embarrassed. By subjecting them to the discipline of filling up a structured form when they have the time to do so , they can provide the key bits of information the doctor needs much more intelligently !

I can also provide reasons for my recommendations , and additional references if needed. Patients are much less stressed out ( studies have shown patients forget half of what their doctor tells them during a consultation) when they email me, which means they remember and retain a lot more of what I tell them, because it�s all in writing. Moreover, this can be an iterative process, because they can ask more pointed queries , which I can reply to.

It�s much easier for me too, because I can reply in my pajamas; and for complex problems, I can refer to my medial journals ! I can also �refer � patients to online information resources, so they become better informed about their problems.

It�s also much easier for my patients because they can ask me queries at their convenience; and they have a written record of what their options are . Patients can also think about their queries; discuss their options with family members; organize their medical records; and structure their thoughts. I now �see� 25 patients in the virtual world ! I find these patients are much better informed and have more realistic expectations, which makes treating them in the real world much easier. This model would work well for all chronic illnesses, such as diabetes , arthritis, hypertension.

One of the limitations of this model is that no personal physical examination is possible, but this is not essential for solving problems in many specialties today. Not only can a history provide a lot of useful information; the record of the primary doctor�s physical examination notes; as well as the results of imaging studies can be very valuable, which often means that a personal physical examination is not even required in the first place.

Medical experts in world class hospitals have been providing second opinions to patients from halfway across the world ( without examining or seeing them) for many years. Doctors are also used to providing useful medical advise on the telephone. Why can�t we use these models to improve the doctor�s efficiency ?

US doctors have become so petrified by the possibility of being sued anytime they write anything down, that they have got paralysed into inactivity ! They can no longer think of innovative ways of providing medical care, because they are so worried about possible medicolegal liabilities . There�s no reason why Indian doctors should allow this irrational and misplaced fear to immobilize them ! We need to capitalise on this opportunity !

We can use this model intelligently and �extend� it using physician extenders. Using a � learned intermediary� ( who could be a nurse , community social worker , family member or caregiver) can help to extend the utility of this model. Maybe a �targeted � physical exam can be done by a trained physician assistant or nurse, who can make house calls and video conference with the doctor ? This could also be done by �expert patients� or peers, for example. I agree that the �human touch� is important; and that an online consultation can be impersonal, but this is no reason to throw out the baby with the bath water.

Doctors have a lot of expertise �we need to tap this intelligently. Many attempts were made in the past which attempted to use �artificial intelligence� to help the doctor to make the right diagnosis. Most of these failed, because I feel their goal was misplaced. Rather than try to use technology to replace human expertise, it would make more sense to use it so that to multiply its efficiency. Amazon�s Mechanical Turk was developed to help solve specific internal data processing problems that required human judgment and intelligence.

It's a clever marriage of information technology and human intelligence. India has lots of medical intelligence, and we can leverage this...

The key would be structured questionnaires designed for each specialty which the patient would need to fill up. The concept could easily be extended to allow family doctors to seek a medical opinion from specialists.

Every specialist need a core of critical information on the patient, based on which he formulates a treatment plan using his expertise and experience. While it may not be possible to capture his experience, reasoning skills or experience, by providing him with the core information he needs efficiently, his expertise can be used much more productively !

This business model would allow expert doctors ( even those who have retired and are no longer in active practice ) to generate more revenue; and also allow patients easier access to medical expertise inexpensively ( because they would no longer be compelled by geographic constraints to going to expensive doctors in the US; or to wait for months and months on a NHS waiting list). This may even galvanize doctors in the US to reduce their expenses; and force them to become more efficient and patient-responsive ! The benefits for insurance companies are also enormous, because these consultant doctors would provide objective evidence based advise, with no vested interests ( since they are not going to be actually treating the patient).


At 4:33 PM, Anonymous Blue Cross of California said...

Great blog I hope we can work to build a better health care system as we are in a major crisis and health insurance is a major aspect to many.


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