Disruptive Innovation: The Future of Healthcare?

Introduction

The doctor–patient relationship, as well as the whole process of healthcare, is becoming increasingly complex with the expanding use of information and communication technologies in medicine. It has been postulated that the future doctor–patient visit will occur “anytime, anywhere.” ¹ In the face of a challenged and changing healthcare system, many researchers are looking to disruptive innovations to revolutionize healthcare. ^2,3 Disruptive innovation is a term defined by Christensen et al. ⁴ and occurs when technology makes a more affordable/accessible service available for a new population of consumers. According to Christensen et al., ⁴ “disruptive innovations enable a larger population of less-skilled, less-wealthy people to do things in a more convenient, lower-cost setting, which historically could only be done by specialists in less convenient setting.”

Christensen et al. ⁴ has also described what he defines as disruptive processes and enablers in healthcare that are moving the field of medicine away from the traditional practice of intuitive medicine to a future of precision medicine. Precision medicine involves the ability of providers to use new technologies, such as on-site testing and imaging, to improve their diagnostic capability. To support this change a shift in the model of care must occur. Christensen posits a facilitated network model where groups of providers work together by communicating electronically using electronic health records shared with patients. Nurse practitioners take on the prior work of many doctors, and primary care physicians (PCPs) disrupt the work of specialists. This shift ultimately allows lower-cost providers to take over some of the work load of higher-cost providers, thereby making the whole care healthcare process cheaper, more accessible, and more efficient.

Asynchronous Medicine: A Disruptive Healthcare Process

Asynchronous medicine operates as a facilitated network model that involves a change in the work role of most of the stakeholders involved in the process of patient care. Providers are enabled to more precisely and efficiently use their own specific knowledge and skills.

Asynchronous medicine significantly changes the role of both PCPs and specialists and enhances the role of patients and nonmedical providers. Patients and nonmedical providers (i.e., caregivers or family members) provide documents and submit much of the core health information required by the asynchronous medicine process by either completing standardized Web-based assessments, questionnaires, and forms, or submitting data from home or mobile medical devices. Common examples include home blood glucose and blood pressure and weight monitoring using wireless devices that automatically upload data. Physicians with specialty-level knowledge then analyze this information and recommend appropriate therapies using evidence-based practice models. These therapies are then carried out by the most relevant and skilled set of providers who may not even have been involved in the original assessment process. This process enables less-skilled providers to provide the same quality of care in a more convenient, lower-cost setting. As a result, asynchronous medicine has become routine practice in radiology ⁵ and other disciplines, ^{6 –18} and could become routine in other more interpersonally interactive disciplines such as psychiatry, pediatrics, neurology, and geriatrics.

A number of medical specialties have utilized and developed asynchronous medicine over the past 30 years, so much so that asynchronous medicine has become a core part of the usual practice. Asynchronous telemedicine is very commonly used in specialties where direct patient contact is not required, including such specialties as telepathology, ^{6 –8} teleradiology, telecardiology, ^{9 –14} teledermatology, ^{15 –18} and teleophthalmology. ^5,19 We will use teleradiology as an illustration of the process.

In teleradiology, remote interpretation of X-ray images and other radiographs is now a routine practice in most major hospitals and has been shown to be highly accurate. ²⁰ Now, radiologists often work from home workstations and occasionally consult across time zones or countries. ²¹ Patients meet radiology technicians, not radiologists. ²¹ It is the technicians who record the images required by radiologists. ²¹ The radiologists then close the healthcare loop by reporting back to the referring provider, or suggesting further interventions and expert referrals as appropriate. ²¹ Frequently, patients are given copies of their digital images on CDs, which they can then bring to their next provider if they wish. ²² This process is an example of a disruptive process where new providers have emerged, and the process has become much more efficient. Each part of the new radiology workflow uses the skills and knowledge of the players involved more appropriately than in the past.

While asynchronous medicine may be established in specialties like radiology, there is little research regarding the use of asynchronous medicine in areas of medicine that traditionally rely on the physical doctor–patient interaction such as primary care, internal medicine, pediatrics, geriatrics, and psychiatry. The practice of psychiatry stands out as a discipline that is highly dependent on the quality of the physical meeting between the doctor and the patient. Yet, even in this specialty, it is possible to utilize asynchronous medicine for some types of psychiatric consultations, using facilitated network business models.

Disruptive Innovation: The Case of Asynchronous Psychiatry

In the traditional model, utilized throughout the world, a PCP refers a patient to a psychiatrist for an opinion. The scheduling process frequently takes weeks or months, depending on geography, insurance status, urgency, availability, and cost. The patient travels to see the psychiatrist after which the psychiatrist sends the patient's diagnosis and recommendations, usually by letter, to the PCP. Treatment and follow-up is negotiated between the patient, the PCP, and the psychiatrist. This is often a very inefficient, slow, and costly process, and the most concerning risk is that patients can get lost because of a lack of communication between the parties involved. Many studies have examined ways of improving the process of primary care psychiatry. ²³ At University of California–Davis, we have developed the process of asynchronous psychiatry to conduct psychiatric consultations in primary care. We are not delivering therapy, but use asynchronous medicine to implement the traditional consultation model of care more efficiently. Asynchronous medicine processes are employed to transfer information for diagnosing referred primary care patients, and recommending treatment plans that can be implemented in the primary care setting by the referring provider and his or her colleagues.

To test asynchronous medicine in primary care psychiatry, we have conducted over 120 consultations to demonstrate the feasibility of this new facilitated network approach to care. With our fully developed treatment model, the patient process is as follows:

a patient is referred to us by his or her primary care provider,

This process obviates the need for patients and specialists to travel and physically meet, or the need for arranging a physical interpreter for a consultation, and makes specialists accessible to patients living in isolated areas who would not normally be able to have such access. ¹ Further, the psychiatrist is able to deliver the typical asynchronous medicine consultation in about half the time than what is normally required for a new patient assessment. This has the potential for patient evaluations to be conducted by a much wider range of psychiatrists. Our experience suggests that these referrals are addressed much faster than typical new patient referrals because the patient consultation can be written simultaneously while watching and listening to the video of the patient interview. Also, this greatly increases efficiency because the consultations can be completed by psychiatrists during down time (i.e., between appointments or during cancelations). We have not formally measured user satisfaction of our process from a patient perspective, but intend to do this in our upcoming studies. We have examined user satisfaction in referring providers in a small convenience sample of 14 patient referrals and the results were very positive. The providers reported the process to be very helpful and efficient and indicated that they would like to continue to refer more patients for this type of consultation in the future. Consulting psychiatrists found the approach to be exciting and innovative as well as a very efficient use of their time.

Our initial experience with asynchronous medicine psychiatry in this specific set of referred primary care patients is that the overall process of facilitated network care is much more efficient, faster, and potentially cheaper for all involved. ²⁴

The Future of Asynchronous Medicine

Real-time telemedicine in many discipline areas is now established with positive clinical outcomes and high patient and provider satisfaction. ^{25 –28} With the increasing availability of digital video cameras and high-speed, high-quality telecommunications, it is reasonable to expect that more programs using asynchronous medicine will be developed. Asynchronous medicine is feasible in primary care psychiatric consultations, and should be equally feasible in similar referred consultations in numerous other medical disciplines. This process allows specialist opinions, such as those that have been provided by radiologists for many years, to be delivered by a wide range of experts.

Asynchronous medicine has a number of other advantages over both traditional in-person doctor–patient consultations and synchronous telemedicine consultations. Synchronous telemedicine typically relies on live, two-way interactive video to a remote area, and asynchronous telemedicine transmits clinical information via e-mail or Web applications for later review by a specialist. The most important of these advantages is that asynchronous medicine is a move toward a multimedia electronic health record that incorporates video as a routine data source. It would be much more clinically efficient to use videos to compare patients before and after treatment situations. This will not only improve monitoring of illnesses such as depression, diabetes, asthma, cardiac disease, obesity, and schizophrenia, but also allows for the demonstration to patients the clear benefits of adherence to treatment. For parents of children with Autism Spectrum disorders, the capture of clinical events on video and their storage in electronic health records will allow parents to show physicians their children's behavior at home. This can also serve as a rich dataset for teaching other healthcare professionals. The adage “a picture is worth a thousand words” is especially pertinent here. Asynchronous medicine gives us the opportunity to precisely capture clinical symptoms on video, which is a much better way of describing symptoms than the traditional methodology in medical record keeping of converting events to text.

From a research perspective, the integration of video and other asynchronous data sets into patient records will allow us to more accurately compare patients across time, and within groups, as well as to collect precise second opinions, without the need for patients to travel. Asynchronous telemedicine can be used anywhere there are visual signs and symptoms. It may be useful in a pediatric population for parents needing immediate consultation about their child's possible dehydration or for a psychologist forwarding video for a psychiatric consultation for possible attention-deficit/hyperactivity disorder. It could also be used in the field of neurology to assess and quantify stroke symptoms more accurately using digital video recorders combined with facial recognition. ²⁹ Asynchronous technology may be used in incorporating computer algorithms in the diagnosis and monitoring of a number of disorders as well as documenting levels of disability much more accurately than we typically do at present. ³⁰

Conclusions

It is clear that asynchronous medicine is a disruptive healthcare process that has the potential to markedly change the way we deliver care in a substantial number of clinical areas. The practice of psychiatry in a primary care setting is an excellent example of this approach. In this model, PCPs become partners with psychiatrists and benefit from rapid and precise consultation feedback through the asynchronous psychiatry process. Collaborative care models for delivering expert treatment have been shown to be practical, efficacious, and sustainable in the treatment of psychiatric disorders, ³¹ and asynchronous psychiatry should be able to be integrated into these models. This model of using videos of patients with asynchronous review by a range of experts should be explored in other disciplines such as neurology, rehabilitation medicine, pediatrics, and geriatrics where it may prove equally disruptive as it could be in primary care psychiatry. Asynchronous medicine, using patient videos and other electronic data sources, is an excellent example of Christensen's business model of a facilitated network, and deserves further exploration in a wide variety of medical specialty areas.