Freeing the “Doc in a Box”

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The American healthcare system is set up to care for a certain subset of the population – sick people – people with chronic disease, acute illness, acute injury, and complex disorders like cancer or metabolic issues.

The problem is, this set up doesn’t create market incentives to care for the well effectively, or to identify those at risk for disease and efficiently and reliably intervene, at scale.

To reconcile this cognitive dissonance between sick-care and health-care, government agencies like CMS, are now funding population-based care strategies. The idea is, the healthcare system should anticipate patient needs at the population level, stratify those needs by risk, and disseminate preventative interventions locally, based on traditional indices like blood tests and screening protocols and emerging metrics like ICD-10 z-codes to identify social determinants of health.

Now that the federal government is redefining the relationship between communities and health systems, it seems logical to anticipate future opportunities to redesign one of the most outdated physician roles – the “doc in the box.”

But the baffling thing is, that is not what is happening.

Despite CMS’ new Accountable Health Communities Model and the NIH’s recent Precision Medicine Initiative, it seems the latest innovations in healthcare delivery are aiming to do what we are already doing – better – to map the genome, decipher codes in our blood, and screen with increasing precision to identify disease earlier and decrease associated health complications and systems costs.

But the building-based, physician-centric, model of medicine America has relied on for decades, maybe even centuries, isn’t serving us well anymore. The hands-on, face-to-face, one-on-one, physician-patient relationship is changing and the bedside, fee-for-service paradigm doesn’t fit how patients access information and more importantly, doesn’t pay for keeping patients well.

Thinking outside the “doc in a box”

In the future, instead of caring for thousands of people in a primary care panel, I think physicians will “care” for hundreds of thousands of people across a grid. And they will provide that care, in teams.

The grid will be color-coded by risk factors. Incorporating data from smartphone usage, credit card spending behaviors, typographical maps of cities that chart access points for public transit, healthy food, parks and recreation, public learning, and other staples of public life. Those access points will be rated by the degree of mobility they generate – socially, economically, and physically. High-rated areas will become models for low-rated areas, and low-rated areas will be first in-line for public resources to re-engineer the environment people live and grow in. This model places mobility, equity, and the capacity to maximize human potential at the center of innovations that create and sustain health.

It also positions physicians among a team of professionals who operate integrated public systems. Those systems will be powered by data algorithms that understand the connections between human physiology and the lived experiences that nurture or threaten that physiology, to ultimately predict risk rather than simply identify existing disease, early.

If future systems can predict risk at scale and are oriented to respond those risks with mitigating resources or information that informs and supports patient decisions, then in the future, physicians will also be expected to be architects of resource distribution, partners in city planning, advocates for social justice, and champions of equity.

There will likely always be a need for physical care of patients with ailments that require  treatments best administered at the bedside. But the advent of technology to provide remote care, analyze multi-variant data that predicts human behavior, and supports patient and provider decision-making with rapid access to information and resources, shifts the future of medical practice outside of buildings.

With a new legion of ancillary providers, it is time to free the “doc in the box” and expand the vision of medical care to include the future of physician practice.

Innovation in Medicine

I am becoming more and more convinced that the greatest opportunity to impact patient behavior and lifestyle choices (the single greatest contributor to one’s health) begin in the community and the idea that a clinic is the catalyst for change or hub of health promotion is obsolete.

What if instead of placing more value (square feet) in “innovative” buildings where doctors exist, we placed value (money) in innovative solutions centered in our communities, where the circumstances that beget health disparities exist? What if some* health issues are really social justices issues – shared problems that are contingent upon resources, access, education, and literacy? If that is true, as I believe it is, then doctors don’t have all the answers and clinics aren’t the only cure.

So the question becomes:

How can our institutions of health bend toward the need and stay relevant in the spaces where people live, work, and play?

I have one idea.

Social media – or the technology and web-based tools used to connect people, resources, and ideas – offers an incredible opportunity for physicians to meet patients where they are, and the data suggests, patients are online. Advancing community engagement initiatives in medicine demands new solutions to complex and challenging problems. Future success relies on how well medicine, as a field, takes advantage of the technology to broadly disseminate credible health information in a space where patients set the agenda. Moreover, using social media to create partnerships between key stakeholders in community health, including community advocates and local and state government, can revolutionize our current models of care and add civic engagement to a physician’s repertoire of treatment modalities.

Admittedly, social media is not the entire solution. But, embracing new technologies to eliminate traditional barriers that prevent the medical system from responding to healthcare needs in holistic and systemic ways, is an important start. Future work must address the potential health disparities that may be created when access to health information is contingent upon access to the internet. However, much is being done to advance mobile health solutions to ensure that everyone benefits from the sharing of information and pooling of resources likely to mark the new age of social media in medicine.

Exploring the uses of social media in medicine is a growing interest of mine and I am fortunate to be connected to a few leaders in the field who are really blazing the trail including Wendy Sue Swanson, MD, Bryan Vartabedian, MD, Ricky Choi, MD, and Heidi Roman, MD. Click on their name and follow them on twitter!

What do you think about social media in medicine?

Footnote: * Some medical problems clearly require medical care that can best be provided in a hospital and/or clinic setting and patients with such ailments rightfully deserve the benefits new technology and innovative medical strategies may bring to bear on their treatment course. This statement is only meant to highlight the growing number of patients who rely on our healthcare system because of problems that currently lie outside the purview of “physician” responsibilities. This illustrates the need for partnerships between physicians, patients, community advocates, and local government to collectively address the needs in our communities that beget major health problems and significant health disparities.