Dyssynchronous – Commentary on the state of video visits

When it comes to digital initiatives, establishment healthcare is a decade or so behind the rest of the world. As usual.

I have previously described my view of how we should expect health that just Is – a seamless blend of technology, product, and service that come together in any channel that makes sense to the member.  Warby Parker has been one of the tech enabled retail darlings to have mastered this consistent, conflict free navigation between the physical and digital.. When originally challenged to distinguish between the channels, Warby Parker CEO Neil Blumenthal called out the false equivalency of ”either / or” when it comes to consumer preference,  “We think the presentation by retail experts of ’either online or offline’ is a false choice. It really is the intersection of the two.”  Blumenthal went on to say that the company uses this blended intersection to find out more about its customers, and thus more about what WP’s evolving business model should look like. This has now become the standard for leading lifestyle brands to emulate: Multi-channel. Data-driven. Personalized.

Healthcare, on the other hand, is treating digital initiatives as yet another strategy to seek reimbursement or increase engagement on the chassis of the old, tired, and traditional health care business model. 2019 is certainly being promoted as (finally) the year of Telemedicine – a coming out party that is 50 years in the making!  The conception has always been: “Let’s solve the access problem by virtualizing the physician visit through video chat.”  No one stopped to think: 1) do people really want to meet and engage a stranger online? 2) what are the conditions that are even amenable to this type of consultation and treatment? and, 3) does a synchronous virtual visit make sense for either the patient or the practice (and will video actually be “a thing”?)

Well, it turns out we have some answers to these questions in the form of a couple of data for perspective:

Linked references for Primary Care visits (CDC), number of urgent care centers, number of urgent care visits, and Telehealth Visits (reversed engineered from Teladoc Annual Report and their 75% market share) and related sector growth projections.

A second view, of video visits themselves, is also helpful to make my point:

Even when just factoring in phone calls, the “utilization  rates” of these services have historically hovered in the 2-3% range, according to industry experts and even telemedicine providers themselves. This is glacier epoch versus the traditional viral pandemic of other digital communication tools. There are different models included within these video visit stats, including “talk to a doctor” where telemedicine connects a patient with, usually, an acute issue to a physician within a phone or video call center.  There is also “talk to your doctor” (or practice) where the telemedicine application extends the access to a personal physician or practice cohort, for after hours issues, in-person visit follow ups or, in some cases, chronic condition management. But in either case, the usage is low, and at best it’s seen by patients as a second-class replacement for the in-person visit, valuable only when access to the practice is challenging.

While there is clearly a need to communicate both in person and within time constraints, both of the above are examples of what I would call a “dyssynchronous” service. In both cases, you are trying to match the needs and availability of the patient, with the capability and availability of a physician. Furthermore, it is still very much 1:1, a traditional office visit or “meeting” between the patient and the provider that does not have any of the leverage made available through technology. The disservice of dyssynchronous really comes to the forefront when you are on the front lines of medicine trying to create a sustainable business. Even when maximally efficient, the inefficiencies of this dyssynchronous approach mean physicians are “selling” their “meeting time” for an average of $45 per visit (which at max efficiency means optimistically 3 patients per hour with average 15 minutes per patient) thereby generating roughly $135 / hour (or $280K annually). This doesn’t make for a viable practice nor does it even approach the more than $2M per year of fees that an employed primary care provider is expected to generate for their hospital masters.

For digital natives, this doesn’t make sense. And as it turns out, for most of the rest of the world video chatting with an unknown physicians doesn’t seem to much sense either (at least not yet based on data). My guess is that to date, there isn’t an equivalent in our culture where videoing with a strangers about personal health issues is within the range of normal experience. When striving for Healthcare that Just Is, we can say with confidence today that video visits are not It.

So what would make sense?

We’ve thought quite a bit about the challenges with dyssynchronous servicse both in terms of “care meeting” matching as well as from the business model sustainability and care delivery leverage perspective. Where we are landing is that we see the future of digital care delivery that will be being asynchronous first, and in person as needed. What we love most about asynchronous is not just digitizing a process (making the physician available through new digital communication tools) but more importantly reimagining what is possible in the “gap” created by the asynchronous delivery model itself. What I mean is – asynchronous creates a space between the patient request (action) and the provider response (reaction) that does not exist within the time-space continuum of an exam room, a video visit, or phone conversation. Asynchronous improves on the limitations of dyssynchronous but more interestingly, it enables entirely new possibilities. The best way to conceptualize these is to consider Quicksilver from X-Men (this “kitchen scene” ought to do it!)

Based on the above, I would diagnose dyssynchronous video visits with a weak and thready pulse, but I remain convinced that asynchronous care is at the heart of a perfectly synchronized healthcare delivery model.