Tuesday, April 22, 2014

Making Health Care More Personal (Again)

Earlier this week The New York Times proclaimed that "House Calls Are Making a Comeback."  I wouldn't get my hopes up just yet, at least not for the old-fashioned version of them.  As I wrote about in my last post, we keep thinking about the past when we should be thinking about the future.

As it turned out, the house calls in The Times article were for very sick patients following a hospital stay -- not anything most of us would want to need -- and it seems that the supposed return of house calls has been trumpeted many times before (see examples from 2013, 2009, or 2006).  It is kind of odd to me that people keep talking about physicians making house calls, because I venture to guess that the majority of the U.S. population hasn't lived in a time when such house calls were common.  Indeed, it may be a sign of advanced age to have actually experienced one.

It may not even be what we really want.

I suspect that "house calls" may be a euphemism for the kind of relationship that patients wish they had with their physician.  After all, office visits are now often squeezed to fifteen minutes or less, and that's after waiting for over twenty minutes, on average.  That doesn't take into account people who simply opt to go to a retail clinic.  None of that is conducive to strong patient-physician relationships.

It may be that our best health care relationship in the near future is not going to be with a physician at all, but with a personal health assistant.

For example, take the start-up Better.  The Mayo Clinic is backing the service, a personal health assistant app that is intended to help consumers deal with the admitted complexity of our health care system. Better relies on Mayo Clinic content and resources, including nurses and physicians that power the personal health assistant.

The free version of Better allows users to get personalized health information and even a symptom checker.  For $49.99 a month, users get the better version of Better, which features a 24/7 personal health assistant.  The assistants can assist with health questions and concerns, and can also help with a wide range of health-related issues, including getting recommendations on physicians in their area, making appointments, or even health insurance advice.  There are limitations on how much the assistants can do due to state laws about practicing medicine, especially across state lines.

According to Better's founder Geoff Clapp, patients are frustrated with not getting enough time with their physicians to form a personal relationship, which he believes Better will allow.  The pricing reflects saving 2 hours a month from dealing with unwanted health tasks.  He and Mayo seek to have 200 million lives (!) using Better by 2020.

It is not clear to me if Better allows users to have a specific assistant on an ongoing basis, or if whom one gets is the luck of the call/click.  "Personal" in the 21st century may be less about dealing with a unique person than it does interactions being tailored specifically to you.

I wish Better lots of luck, but if they get to 200m users - or even half that -- then our health care system is even more screwed up than I thought.  I guess if we can't actually reduce the complexity in our health care system, the time-honored solution is to add another layer to try to manage it better (no pun intended).

Plus, at $50/month, concierge medicine starts to become more competitive; the services are not identical, but many patients may like the in-person option concierge medicine allows.  Or they'll take advantage of options like the American Well retail option, which charges $49 per tele-visit, but which I'm guessing will someday morph into a per-month option as well.

Of course, there's nothing particularly new about personal health assistants (or health coaches).  Most of them have been provided through health plans or employers, such as through Accolade or Healarium, but there have been other retail personal health assistant services, including Allayo and Humana's HomeCare Solutions.  Better brings the powerful Mayo brand into play, continuing to broaden its reach.  They are already a leader in the use of social media.

Thinking even more futuristically, there are already "virtual" personal health assistants.  NextIT developed Alme, a virtual assistant, and has versions of it for multiple industries (including Aetna's customer service version "Ann").  Last fall they announced their health care virtual assistant, which they say can assist not only with administrative problems but also clinical questions.  They see Alme not so much as a consumer solution but rather as a solution for health care professionals to assist with patient demand, which strikes me as very 20th century thinking.  Toshiba has already partnered with NextIT to provide solutions for Toshiba's tablets and laptops aimed at health care professionals.

Many people think that Apple's virtual assistant Siri will soon be able to take on health care concerns, which would fit in neatly with Apple's rumored interest in health.  Mayo is going to have a hard time staffing Better with real people if it does get those 200m users; one way or another, the personal health assistant business is going to have to rely heavily on virtual assistance if it is to scale.

The implication of all this is that instead of house calls from -- or even office visits with -- a physician, we may prefer access to a personal health assistant that is available anytime, anywhere, with little or no wait, and which may or may not involve humans interactions.  Technology is changing not only what we can do, but also our expectations. 

Intel's Healthcare Innovation Barometer, released late last year, found that consumers are optimistic about technology advancing health care.  More than 70% were receptive to remote monitoring, and more than half reported being as or more confident about a test they administered as they would one done by a physician.  They're not waiting for their doctor to tell them what to do, and, in fact, they don't want to have to wait for him/her at all.

While we're rethinking the need for patient-physician visits, we should be rethinking other aspects of our delivery system as well.  That same Intel survey found that 57% think traditional hospitals will be obsolete in the future, something I agree with.  Many hospitals have tried hard to rebrand themselves as being in the broader health business instead of in the medical business, such as through fitness centers and more emphasis on holistic medicine.  Heck, the Cleveland Clinic now has an herbal therapy clinic.  Other hospitals are trying to design their campuses to be less medicine and institutional and more integrated into the community with a wellness focus

They need to keep trying.  Personally, I'm still trying to understand why the Hospital at Home movement has not taken off.

We're still getting our health care from a system that, for the most part, relies on us going to buildings in order to get care and advice, and to get those from physicians.  That system still strictly circumscribes what only physicians can do, and in which physical areas they can do even that.  It's a system of hierarchies and institutions, of having to ask permission, and in which patients are people things are done to, not people who actively do things for themselves.

But we live in a world that is increasingly virtual, where information is broadly available and flows freely.  We live in a world where remote monitoring becomes more and more viable, and which bionics will revolutionize further, especially as we figure out how "Big Data" can make all that data actionable.  We live in a world where artificial intelligence and algorithms are getting smarter and smarter, and which may now or soon be more able to process and use the torrent of medical information and research than physicians can. 

I don't need to ask any personal health assistant which world I want to get my care from.


  1. I'm having trouble imagining myself wanting medical advice from a health assistant. Anyone else?

    1. Totally understand - we have 24/7 nurses available (Mayo Nurses) as well as other resources, so you are getting the care from real, licensed, experts. There are multiple people on your care team, of which the Personal Health Assistant is one, but totally understand and agree - this is not just "any" health coordination - that's a very fair question and point.

  2. Hi Kim,

    Thanks for the article, we have a very similar view of the world and the future of medicine, care, and delivery.

    Using technology to scale great providers - rather than replace them - is really our shared goal with Mayo, and why they is such a great collaborator and investor. No physician lead organization wants to see computers take over the bedside, but also realizes the importance of technology in providing care at scale. That line where humans and technology meet in healthcare is the most interesting problem to me. The EMR debacle is just one example of how it can go horribly wrong.

    It's interesting about the 200MM number (which actually is not our number, just FYI) but when you look at total monthly unique on many websites that deliver non-personalized, static content - it's 30-50MM per major healthcare site.

    So the idea isn't totally crazy, be it our number or someone else's, that in the next six years we could grow that 4x. Of course not all of those people need a person (especially not all the time) - the right level of care (and cost - most people will use the free version)

    Anyway, it's a long, curious, challenging problem, and I'd love to discuss it more.
    You can reach me anytime at geoff@getbetter.com