Automated Virtual Primary Care: A Health System Opportunity
by Phil Marshall M.D., Co-founder and Chief Strategy Officer, Conversa
According to the Kaiser Family Foundation, comparing the US per capita to European nations, Australia and Japan…
- The US ranks first in healthcare spending
- The US ranks last in life expectancy
- The US ranks first in the burden of disease
- The US ranks last in physicians per capita
- The US ranks first in health disparities related to income inequality, and
- The US ranks last in access to affordable, quality care
Our lack of access to quality care, directly related to its high cost and the low availability of physicians, has resulted in chronic conditions, behavioral health issues, and new symptoms progressing to being more uncontrolled in the US than in any other country. This then results in more hospitalizations, more procedures, worse outcomes, and much higher costs. And these issues are compounded in underserved populations. For example, while 25% of all US adults lack a primary care physician, Black and Hispanic adults are significantly less likely than their White counterparts to have a usual source of care.
Primary Care, including family medicine, pediatrics, internal medicine, geriatric medicine, and gynecology, is widely recognized as critical to addressing these problems. According to the Primary Care Medical Home Resource Center, primary care can “meet the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care.” But according to the Association of American Medical Colleges, the US will have an estimated shortfall of up to 55,000 primary care physicians by 2033. This represents a third of the capacity needed to satisfy their proactive and preventative role. Vastly expanding the number of primary care physicians to meet the health care needs of our nation, therefore, is not feasible, and doing so would further deepen our spending crisis.
With the help of technology, however, many of these challenges can be overcome. The time may finally be right. The US has ubiquitous use of electronic health record systems (EHRs), and those EHRs are now required to have Application Programming Interfaces (APIs) for greater data accessibility. This will usher in a new era of data liquidity and enable structured EHR data to be put to work on the patient’s behalf. Automated Virtual Primary Care will be a significant beneficiary of this change.
And while Internet-based technology has been stigmatized as creating a “digital divide” that discriminates against the elderly and the economically underserved, according to Pew research over 80 percent of all ethnic groups, including over 80 percent of Medicaid beneficiaries, have a smartphone. When combined with the rising prevalence of broadband service, Internet-based applications have quickly become the most accessible and least discriminatory modality for healthcare delivery. Automated Internet-based engagement can meet patients where they are- in their language, at their level of literacy, and automatically address their personal needs while limiting systemic bias across the medical, behavioral, lifestyle, and preventative domains. In fact, it’s now well accepted that patients’ interactions with electronic systems are more forthcoming and honest than their interactions with physicians.
Conversations: The Key to Healthcare, Old and New
It’s estimated that half of the $2 trillion we spend each year in the US on hospital and physician services is on synchronous conversations with patients. That may come as a surprise, but adding up what gets billed for in healthcare – office visits, phone calls, and telehealth visits – our spending is largely driven by episodes of care in which little more than conversations occur. Even most of the days spent in the hospital are for nurses and physicians to check in on the patient’s recovery.… again, conversations.
Despite all these conversations, we’re left with a terrible cost and outcomes crisis. In other words, we seem to be having a lot of the wrong conversations, largely due to primary care not having the capacity, per above. The potential to start driving the most effective conversations is tremendous. According to an analysis conducted by Conversa, the number and types of digital conversations are vast. Note that the majority of potential conversations are in the support of managing a condition or known issue, the vast majority of these conversations (~83%) can be automated, and any conversation potentially escalates into telehealth services as needed.
Introducing Automated Virtual Primary Care
So what is Automated Virtual Primary Care? At its core, it is the automation of conversations between a care team and their patients, including the collection of patient-generated health data (PGHD), and personalizing automated guidance, support, and education in response. Some refer to this new model as “robotic care,” “chatbots,” or simply “bots.” This becomes an automated extension of the primary care team, expanding the total population manageable by a single team and increasing patient contacts. When used as an extension of the physician and the team’s care, Automated Virtual Primary Care is starting to show impressive results:
- Northwell, the largest health system in New York, found that deploying Automated Virtual Care with daily automated conversations to Medicare patients after their discharge from the hospital reduced readmissions by 32 percent and doubled the capacity of their nurse navigators
- Ochsner Health System in New Orleans found that Automated Virtual Care conversations every week with uncontrolled hypertension patients resulted in a 21 percent improvement in blood pressure compliance, which is associated with reduced stroke rates by over 30 percent
- A primary care clinic using Conversa’s diabetes chats improved HbA1c compliance by 25%, correlating to a 20 percent reduction in medical spending
- Prisma Health in South Carolina found that Automated Virtual Care cut in-person evaluations for COVID symptoms in half while tripling its lower-cost Telehealth visits for these patients
- Long Island Jewish Medical center experienced a 48% reduction in cancellations and no-shows for screening colonoscopies as a result of an Automated Virtual Care bot.
With the estimated 2000% increase in telehealth utilization under COVID, there is a tremendous opportunity to expand upon the health system’s telehealth and clinical service footprint with Automated Virtual Primary Care to create a comprehensive offering. The opportunity for such a service could be significant. According to McKinsey in their May, 2020 analysis, approximately 20 percent of all emergency room visits could potentially be avoided via virtual care offerings, 24 percent of healthcare office visits and outpatient volume could be delivered virtually, and an additional 9 percent “near-virtually.” These changes add up to $250 billion in healthcare spending (2020) that could be saved by virtual care, or 20 percent of all office, outpatient, and home health spend across Medicare, Medicaid, and commercially insured populations.
Integrative, Configurable, Automated, Personalized Ongoing Conversations
Conversa enables healthcare delivery systems to configure, brand, and use its automated, personalized conversational platform as an extension of their core primary care service offering, with custom-configured pathways, rewards redemption, and reporting dashboards. This can also be a comprehensive offering for employers as well, with integrated escalations into service line-specific telehealth or other resources. The chats would be triggered with notifications up to once a week, and available on-demand for new symptoms and education.
The Conversa solution is proposed to re-analyze each patient’s risk in four areas, or pillars:
- Medical Management, including the integration of data from connected devices
- Lifestyle Management, including the use of data from connected devices
- Preventive Care Management
- Behavioral Health Management
Constant re-evaluation of the pillars can provide a year-over-year benchmark and comparison that can monitor the success of the health of the population.
Complementing the Four Pillars is an “Always on” symptom triage module smartly triaging the patient to appropriate health system resources. Symptom “domains” such as pulmonary symptoms are analyzed for severity and routing to the appropriate resources, including community, telehealth, coaching, in-person appointment, or online education (watchful waiting).
The Key to Automated Conversations: Profile-driven Personalization
For an Automated Virtual Primary Care solution to be successful, it has to engage the patient or their caregiver with timely questions, guidance, support, and education that helps them to improve their lives. While techniques like Self Determination Theory (SDT) can be used to ensure empathetic language that supports the patient’s autonomy and competency, the conversational topics must understand the patient’s health concerns and past history.
The Conversa system is built around a longitudinal profile driven by clinical history, connected device data, and the patient-generated health data (PGHD) collected through automated conversations. By overlying provider-approved pathways that are constantly re-evaluating the patient’s profile, dynamic conversations can be delivered to the individual while still being fully vetted and approved by the provider.
Summary of Conversa’s Automated Virtual Primary Care Solution
In summary, Conversa’s solution to extend a health system’s primary care capacity using Automated Virtual Primary Care is…
- Automated: The solution will automatically notify the patient, trigger a personalized chat, then automatically escalate into a higher level of care as needed
- Personalized: The patient’s profile is always changing, and so should the chats, personalizing each of the elements as well as the chat frequency
- Integrated: Workflow integration, including alerts and EHR integration, ensures that the results of the Conversa real-time risk analysis are surfaced to the care team as needed
- Comprehensive: Chronic care, lifestyle management, behavioral health, and preventive services… the automated solution systematically covers the primary care landscape
- Always on: The bot will always respond when a patient starts it, even if no chat is scheduled. Systematic coverage of new symptoms and education have you covered.
- Intelligent: As a digital-first strategy, Conversa is able to triage and escalate patients into the proper level of care – telehealth, phone calls, eVisits, or in-person visits – ensuring that these synchronous services are used for the patients at the right time.
A note about the role of payment reform and regulation in this emerging field:
Just as payment parity has helped the telehealth industry expand, so too is there the need to support the emerging Automated Virtual Care industry. Conversa will continue to engage its health system and legal partners to motivate positive changes needed to support this transformative technology. We advocate for long-term reform to support bot-driven care, as well as near-term steps that can be taken, such as outlined in our public comment on the 2021 Physician Fee Schedule, located HERE.