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Scott Shreeve, MD

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I'm the CEO of Crossover Health, a patient-centered, membership-based medical group that is redesigning the practice, delivery, and experience of health care. We offer urgent, primary, and online care to our members who can access our technology platform, practice model, and provider network from anywhere and anytime to optimize their health. Email Me



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Health Care Value Chain: Moving On Up!

Value Chain (văl’yū chān) n.

1. A sequence of value-enhancing activities
2. A chain of activities that gives the products more added value than the sum of added values of all the activities.

Last week I was able to participate in a very cool live podcast with the ReadWriteWeb editor Richard Macmanus. While I am still finishing up my commentary based on that experience, I did want to comment on another post by Richard who is one year into his diagnosis of Type I Diabetes. He mentioned that his favorite Health 2.0 application was MyMedLab.

In full disclosure, I serve as an advisor to the company as well as a participant on the call that was conducted. I became involved with MyMedLab while conducting my own survey of promising Health 2.0 companies, tools, and technology. I was intrigued by their Health 2.0 delivery model of leveraging the internet to remove inefficiencies of time, location, and physician approval for routine wellness laboratory testing.

I became convinced after using the service for myself. Since I hadn’t ordered lab test since my medical school entrance physical exam, and I was preparing for an upcoming physical, I ordered the baseline wellness tests I knew my primary care provider would want (conveniently organized by “profiles” – individual tests that are grouped together to provide disease or organ system specific information). I wanted to maximize my time with my doctor and come prepared with as much information to review during our appointment as I could.

MyMedLab helped me accomplish these objectives in a cost-effective, convenient, and confidential way. It was a hassle free ordering process and I had my results within 36 hours. I was able to fax this information to my physician ahead of my appointment and to actually use some of my time with him to review the data as opposed to discuss ordering the test. I immediately saw the opportunity to extend this to other appropriate settings, and other appropriate patient or physician groups who have highly specialized laboratory testing needs (hormone health specialists, bariatric patients, and even diabetic patients).

A persistent question that comes up is the appropriateness of the direct to consumer model. I have to agree with John Sharp about the age of “paternalistic medicine” going bye-bye. I discuss this at some length in a previous article entitled, “The Millennial Patient” .The easiest analogy to understand this point is to review the democratization of the financial services sector. 30 years ago, only qualified financial advisors could provide financial advice, set up accounts, trade stock, transfer funds, or manage a portfolio. Can you imagine that being the case today? Consumers have the ability to read financial information (now abundantly available), set up accounts in minutes, buy/trade stocks with a click of the mouse, move money across the globe between multiple accounts, and manage all their accounts from single portals all without leaving their desks.

Does this obviate the need for financial advisors? For many smaller or DIY investors, it has reduced the need by outsourcing these functions to the consumer. However, the experience and knowledge of a trusted financial advisor is still heavily relied upon for anyone requiring professional assistance, complex trading, or needing higher end service. They haven’t gone away, they have just had to adapt what they do, how they provide their services, and who their customers are. In essence, financial advisors have had to move up the value chain.

While this will sound heretical to some old school doctors, most wellness laboratory exams don’t need to be interpreted by a physician. In fact, most wellness exams don’t need to be performed by a physician. It is pretty straightforward stuff: Cholesterol 250 = get on some cholesterol lowering meds. This isn’t rocket science.

However, there clearly is a time and a place to call upon those practiced both in the art and science of medicine. I assert that the trusted physician advisor will be as meaningful, if not more meaningful, to you in the future world of highly personalized medicine. You might interact with her in new and exciting ways – chat, text, videoconference – but she will continue to use her expertise, knowledge, and experience to provide the advice you need on key health issues, disease states, and medical treatment plans. Physicians aren’t going away – they will just be practicing at a higher, more meaningful level than they have in the past. Physicians, like other knowledge workers, will have to move up the value chain in order to maintain their relevance in the future.

Most will. Some won’t. And for any of those clamoring that they are the only ones authorized to read lab results, send them the this link along with an email saying you are looking for a new physician.

(Oh, they don’t do email? You should have left long ago!)

5 comments on “Health Care Value Chain: Moving On Up!

  1. PookieMD says:

    I guess I may be one of those “old school” doctors you refer to. I think that handing patients a bunch of lab values with out guidance is poor medicine. There are many labs on a chem 19, for example, that don’t have a lot of meaning. Many patients will call anxiously and ask about these meaningless labs. I think there is a reason that medical school is 4 years, and that residency is a minimum of 3. I love informed patients, but the internet is not a physician, and last time I checked, wikipedia couldn’t do a physical exam.

  2. PookieMD,

    Thanks for your comment. I agree with you – the internet is not a physician and never will be. It is simply a source of information and a mechanism to increase efficiency by removing time, geography, and process friction.

    I am not advocating “handing patients a bunch of alb values without guidance”; or ordering meaningless test or creating confusion for patients who want to understand the significance of an “abnormal” sodium level of 149. The process at MyMedLab and most other reputable Direct To Consumer testing companies is to provide a physician to review the lab results when they are received. Immediately. I don’t think most physicians have the time nor inclination to provide that level of service, but it can be done using the internet. I believe you would agree that this is “good medicine”.

    As I mentioned in the post, this does not obviate the need for a trusted, ongoing relationship with a physician who can add clinical context to the lab results and help you track progress over time. I never said, nor would I advocate, that going pure DIY is a good idea when you are talking about your health.

    What I am saying, is that I am not going to burn up 5 of my 12 minutes with you discussing ordering lab tests, but instead reviewing the results. Also, who says that these tests are being done outside the bounds of a trusted physician relationship? A much better approach is to discuss with your physician ahead of time what labs you can order to prepare for the visit (would you having patients who email you ahead of time knowing how they can maximize their time with you?). The answer might be none – or it might be – hey I always order these test regardless of any evidence because I was trained to do it that way and it is nice to have a baseline (come on admit it) – and MyMedLab and similar services provide a cost-effective, convenient, and confidential way to do this.

    Best practice, and best evidence, is that having a trusted primary care relationship with a physician will lead to best care, quality, cost, and outcome. Best practice for millennial physicians will be to help their patients achieve that end – including advising their patients on a cost-effective, convenient, and confidential way for them to track their labs over time.

  3. Scott, I’m totally on your side on this one. Granted, as a clinical pathologist I’m not the one in the exam room talking with the patient about their results, but my family’s and my own experiences as a patient are sufficient to tell me that direct access lab testing is a good trend. There’s abundant evidence that doctors and doctor offices do a very poor job communicating with patients regarding their lab results. (See Boohaker EA et al., Arch Intern Med. 1996 Feb 12;156(3):327-31) And even for those who do a good job, is it a bad thing for patients to be knowledgable? For patients, information is central to their ability to be an active participant in their own care, and lab information is a big part of that.

  4. How about this: build a system for the patient’s PCP doc that intelligently and automatically pre-orders routine exams and tests, facilitates the scheduling of these tests between the outside facility and the patient, and provides an automated mechanism for the results to be reported back to the PCP, all prior to the patient’s visit. Taking the PCP out of the loop of the patient’s care in any way, shape or form is bad medicine. Don’t try to come up with a way to make money by capitalizing on “consumer-directed” healthcare with impersonal, dangerous solutions. Instead, focus on really solving the problem.

    1. Brendten,

      Now we are talking. I like where you are going with this . . . however I want to make sure you understand my point about the value chain.

      Think of MyMedLab or any of the other resellers as a tool that either the patient or the physician can use. We love it when we have a physician who works with us to direct patients to us, or when patients have orders from their physician. We are not opposed and actively support this model. In fact, physicians can become registered MyMedLab providers to provide order approval and results release compliance for their own patients using MyMedLab physician portal. This meets your criteria of “intelligently and automatically pre-ordering routine exams and tests” as well as “results to be reported back to the PCP all prior to the patients visit”. Challenge we have experienced is that most physicians don’t have the time, interest, or inclination to be available to their patients to help with even this simple, yet effective use of time for routine testing needs. We have the capability and we welcome this type of collaboration.

      Unfortunately, I disagree with you about “taking the PCP out of the patient’s care in any way, shape, or form is bad medicine”. Do you know that the quality scores from Nurse Practitioner only Minute Clinics is OFF THE CHARTS? 99% compliance on standardized protocols for routine, non-emergent health care needs. Exceptionally high customer and provider satisfaction and excellent clinical outcomes. That is NOT bad medicine – that is the BEST PRACTICE. However, the cookie cutter only works for cookies, not for bread, rolls, or other delights. Patients are best served when they have a long term relationship with a trusted physician advisor. However, they don’t need the skill or ability or expertise or the cost of a physician for certain things. My point is to get the doctor to be involved but to only do those things that actually only a doctor can do – move up the value chain. In the case of swabbing tonsils and making clinical judgements of ear infections, skin conditions, etc other health care professionals can be adequately trained to manage. Nurse practitioners have a clear scope of practice, and I would argue that intelligent, engaged patients can have a scope of practice as well.

      That should contribute to “really solving the problem”.

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