Making Virtual Primary Care Viable

Published 2020.1.13

Information technology adds value outside of healthcare by minimizing low-value, high-variation human interactions through processes that can be scaled across wide geographies and large populations. In its most extreme form, information technology can replace intermediaries altogether by connecting consumers with sellers directly over an interactive interface. The most successful information technology deployments identify the consumer’s specific needs to then provide that consumer with enough information to make a decision about where to obtain a good or service and then connect the consumer to the desired service. In the last decade, transportation (ridesharing) and entertainment (music, television, and movies) have been completely transformed and other industries (banking, real estate, education, and agriculture) have been markedly changed by information technology. Most health information technology has been used to address use cases that support existing processes without considering how healthcare delivery might be reimagined to meet patients’ needs (e.g., online appointment scheduling instead of removing the need for appointments altogether, replacing the fax with online transactions instead of addressing the overwhelming number of transactions required to complete “simple” tasks).

Virtual health could radically change how providers might deliver healthcare to better support patients and their caregivers. Many of the concerns about virtual health seem to focus on the increase in utilization without a corresponding decrease in face-to-face encounters. More recently, telemedicine has been suggested as an approach to provide individuals with more access to primary care when there are no primary care provider geographically nearby. Primary care includes many interactions beyond the low-acuity, new problems that have traditionally been managed using telemedicine.

Bashshur et al. suggest primary care serves three functions: first contact, gatekeeper and manager/coordinator. The authors acknowledge that primary care as a concept supports a desirable social goal: the optimal level of health for the maximum number of people in the community. Despite primary care’s inability to address all of our patients’ health care needs, primary care is believed to guarantee access to care, provide a continuous relationship with a physician and provide a personalized referral to a specialist when needed. To meet Bashshur’s “gatekeeper” and “manager/coordinator” roles, virtual primary care will need to engender trust among patients who are not in the same room physically. Discussions about preferences and probability can be had over telephone and video chat, but some of the value of a primary care provider for the patient and the healthcare system is the ability to defer testing or treatment for some conditions that may either be premature or lead to diagnostic cascades with more costs than benefits. In 2001, Bowman argued that success in primary care will depend on:

  • An emphasis on quality of care,
  • Dependence on new technologies to enhance quality,
  • Availability of and access to primary care for the entire US population,
  • Increased political power for the family practice specialty,
  • Enhanced research and funding, and
  • Learning to work with patients so that they are the masters of their own care.

Bowman’s arguments to use technology to enhance quality and to empower patients resonate most strongly with me for all interactions between clinicians and patients. For those encounters through virtual primary care, clinicians will also need to consider the impact of technology on their interactions with patients during the encounter and afterwards.

Bashshur et al. other findings included:

  • Patients would prefer physicians suggest authoritative and commercial-free sources of health information rather than searching the Internet blindly,
  • Patients already use their smartphone for health purposes, including:
    • Finding health or medical information,
    • Downloading or using a health application, or
    • Tracking/managing a health issue (e.g., diet, weight, activity, mood, blood pressure).
  • Online tools to assess quality-of-life and diagnostic questionnaires could be adopted by some patients,
  • Automated phone calls for appointment reminders, medication adherence, health monitoring and education are welcomed by some patients,
  • Providing family physicians with information from an emergency department actuallly increased the number of duplicate specialty consultations, and
  • Electronic consults can increase rapid primary care follow-up rates compared to usual care.

Ashman et al. reviewed the National Ambulatory Medical Care Survey 2016 data. Here were the major reasons for office visits among adults:

Major reason for office visit, by age group (years) Percent
Under 18 – New problem 41
Under 18 – Preventive care 32
Under 18 – Chronic condition 17
18-64 – Chronic condition 37
18-64 – New problem 24
18-64 – Preventive care 24
65 and over – Chronic condition 51
65 and over – New problem 21
65 and over – Preventive care 15
Major reason for office-based physician visit, by age: United States, 2016
NCHS Data Brief No. 331, January 2019

Although telemedicine has been studied extensively in the low-acuity new problem domain, the opportunity to meaningfully impact ambulatory care, at least for patients over the age of 18, may be better served in the chonic care space. Most of the literature I have reviewed has been silent on using telemedicine to address primary care visits through virtual primary care.

Some elements of a scalable virtual primary care offering might be:

  • Tools to provide information about when a virtual encounter or face-to-face encounter might be appropriate,
  • Secure communication with patients and caregivers,
  • Process to manage information from remote patient monitoring devices,
  • Deliver tools to facilitate diagnosis, treatment or estimate prognosis,
  • Record patient preferences and track those preferences to support conversations about advancing or forgoing a diagnostic or treatment decision,
  • Ability to send and receive patient health information to other members of the healthcare team (e.g., consults, procedures), and
  • Support long-term behavior modification.