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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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When we think of the broad impact of technology in our daily lives, our first thoughts are often to how much faster technology can help us accomplish our work. Complex interactions can be abstracted away as processes are automated or optimized; efficiencies can be gained that remove friction and facilitate transactions; and, we often think of these efficiencies in terms of making our lives simpler while SAVING time. What’s even better, most of these gains can be achieved using our mobile devices – whether booking a hotel, hailing a cab, or communicating with friends – and this convenience, accessibility, and mobility can make it all seem like magic!

But one aspect of technology that I have not previously considered is how technology can be useful in EXPANDING time. I am not talking time dilation as in the Relativity Theory sense, but I am talking about time expansion in the creation of a “pause” in time due to the asynchronicity nature of certain technologies.  Let me explain.

The definition of “asynchronous” is kind of bland, and straightforward: “not simultaneous or concurrent in time.” So much of modern life is “faster” but the speed is often due to the asynchronicity of how we work.    Email was the first pervasive electronic messaging medium to leverage the unique “features” of asynchronous communication, and arguably it’s still the best. We’ve learned that an instant response to an email message is not required, and that it’s actually better to send a considered answer back some minutes, hours, or even days later which can be perfectly, socially acceptable. It’s not only become protocol for email, it’s now ingrained behavior by which people intentionally use this channel as a form of digital long form communication.

Asynchronicity, and the “power of the pause” have not been fully leveraged in healthcare just yet. In fact, our prototypical use case – email – has not been utilized much at all because within health care there has not been a business model that effectively compensates physicians for their time to consider, compose, and send an email. As a result of this business model problem, a well known, widely used communication tool is not an integral part of practice and care relationships (there are many other unfortunate examples of tool / intervention that aren’t utilized within modern healthcare because of the current reimbursement paradigm not valuing the tool / intervention – but that is another post!).

Let’s assume that we have solved the compensation issues with asynchronous communication and email (and at Crossover Healthwe have!). With the right business model in place, “asynchronous” is a powerful, and I believe more appropriate, form of communication that can and should be deployed more pervasively in primary care. In fact, I believe the asynchronous approach to communication solves three “synchonous” problems in primary care:

  1. “Care meeting” matching. Asynchronous forms of communication eliminate the challenge of coordinating schedules for the “meeting.” Physicians are busy, their schedules are unpredictable, and we are notoriously late because of constant interruptions throughout their days. Patients are also busy, their schedules are challenging to match, and perhaps most problematic for healthcare is that multiple other service industries have solved this matching problem with digital enabled services that have become the new norm. Physicians have no shot at “attending” to email given that neither their daily schedule nor their business model accommodates this. Asynchronous allows meeting matching to happen naturally, and the physician can be focused, contemplative, and considered in the response. The efficiency of being able to sit down and focus on a response is powerful. Working through the queue uninterrupted, and having access to resources to include in the response, such as hyperlinks to articles, references to educational material, and related meta-information can significantly enrich this form of communication.
  2. Care delivery leverage. One of the biggest challenges for traditional primary care is that there is no “leverage” (the ability for the resources to scale to match the work).  Synchronous primary care is all about in person meetings – 1:1 relationships fully dependent on a single resource, and the associated time, cognition, and multi-tasking limitations of the provider as a “resource”.  Solving meeting matching as described above is just the beginning of asynchronous leverage. Think also about the time efficiencies gained from reducing context switching, cognitive parallelism, and even the efficiencies gained when you reduce the natural in-person “lag” in natural conversation (social pleasantries, question / response tracking, and having to repeat or reiterate). These communications can be an important part of building trust, but they are “inefficient” from a technical perspective nonetheless. Asynchronous reduces or removes most of this lag and allows one to maximize the value of time at each interaction, which quickly aggregates to significant time expansion throughout a routine day.
  3. New business model possibilities. Finally, what we are most excited about at Crossover is the opportunity for the “power of pause” to create new business opportunities. Think about a pretty routine physician order – a chest x-ray that needs to be sent out. Currently, that order is processed, someone makes a phone call, the patient shows up for the appointment, and if you are really lucky the result actually comes back in some version of a “closed loop” process. In an asynchronous world, the order is made and there is a pause in which value can be added to the order itself. A value added partner like Lyft might be able to send a quick note about a transportation option to the diagnostic imaging center. The radiology center can send the patient directions and prep instructions. The provider can do some research about the condition and share some information about the test itself or potential followup for the test. Billing and financial credentials can be shared ahead of time to make the payment processing easier. On and on. My point is that within the asynchronous pause there are myriad possibilities to add value and create new member experiences we have not considered before – at least in healthcare.

What about other messaging environments like Slack, Messenger, Whatsapp, WeChat, etc? In general, these have fostered different behaviors that are much faster, less formal, and more “chatty” (quick thoughts, half sentences, abbreviations, emoji’s, etc). This back and forth banter, the real time injection of ideas from multiple parties, and the coordination of distributed teams and their ideas play out in near real time. These successful messaging apps have created new norms by conditioning users to the bursty nature of this communication style. While the use case for these tools has been strong in fields that require collaborative development, fast ideation, and distributed coordination, they are less compelling and I would suggest less effective in fields that require significant cognitive load, considered pattern recognition, and deep mental work.  I would wager as the cognitive processing requirements goes up, the more considered the use of a communication tool needs to be. That said, aspects of some of these apps like Slack (where team based problem solving is central) will have a role to play in our model of care as well.

Asynchronous represents a powerful addition to the diagnostic, therapeutic, and treatment armamentarium of care teams. Many of these opportunities are made possible by technology, but are enabled by a business model that rewards care teams for the value they create and the persistence of the relationships they establish. By expanding time, asynchronous allows teams to add value in new ways previously not possible. We will continue to explore these possibilities and the associated ramifications of our digital first approach in the months ahead. Our big bet is that with asynchronous care at the center, we can really make time for better health.

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