Health Care Communication Technology and Improved Access, Continuity, and Relationships: The Revolution Will Be Uberized

Rapid changes in technology have created the potential for a major disruption in health care. A host of new health care companies claim to want to revolutionize health care in the sameway Uber and others are revolutionizing transportation. Companies such as Pager, Medicast, Heal, and RetraceHealth allow people to summon nurses and physicians to their homes. Studio Dental brings a mobile dentist office to workplaces. Companies such as Zipdrug and Postmeds provide on-demand pharmacy delivery. Teladoc, AmericanWell, MeMD, MDLIVE and others address urgent care problems by providing online access to physicians. During this proliferation, some have asked whether patients, in the search for accessible, on-demand care, are sacrificing continuity or quality.1 In this issue of JAMA Internal Medicine, Schoenfeld and colleagues2 examine the quality of care delivered by companies that provide online access to physicians to evaluate urgent care problems. They report on the care receivedby anunannouncedstandardizedpatient,or“secret shopper,”duringan evaluation of low-acuity urgent care delivered by telephone, text, or video. The investigators trained standardized patients to present 6 common low-acuity illnesses to physicians at the 8 largest commercial online urgent care companies. History andphysical examinations—such as could beperformed remotely—were complete in 69.6% of visits. Physicians named the correct diagnosis in 76.5% of visits and provided guideline-adherent care in 54.3% of visits. Antibiotics were frequently prescribed inappropriately. Physicians prescribed antibiotics to half of patients reporting symptoms of viral pharyngitis or viral rhinosinusitis (5 days of sinus symptoms without fever). For these 2 illnesses, among the 8 companies, antibiotic prescribing ranged from 12.8% to 82.1%. Physicians generally did not order additional testing, whethertheguidelinesrecommendeditornot.Physiciansfailed toorderrecommendedtestingin65.8%ofrecurrenturinarytract infection cases and 84.5% of ankle pain cases, both of which are instances where additional testing is recommended. However, the low rates of test ordering probably contributed to better physician performance on the back pain scenario: clinicians correctly did not order an x-ray for 93.1% of visits. Critics of online care will look at the study by Schoenfeld and colleagues2 and conclude that online care is low-quality care. However, the investigators did not use a comparison group, and these secret shoppers might have fared similarly, better, orworse at their primary care physician’s office or a retail clinic.3 Most settings have demonstrated wide variability and plenty of room for improvement. Despite concerns raised by this evaluation by Schoenfeld and colleagues,2 we will continue to see more and more patient care facilitated through novel communication technology, particularly for low-acuity urgent care traditionally delivered in the primary care setting. Whether this constitutes the conversion of fragmented encounters into a seamless experience depends on how it is converted and who is driving thechange. Inananalogywith transportation,mostof thenew companies, like those examined by Schoenfeld and colleagues, are like traditional taxi cabcompanies.Theyusemodern communication technology, but they provide a fragmented, one-off experience. An Uber for health care should be a full-service platform that facilitates communication and care coordination. Moreover, as in transportation, important but surmountable barriers remain to the successful integration of patient technology in health care. First, Uber uses GPS-enabled smartphones to match immediate demand to slack transportation supply. Although health care feels like it has unlimited demand and severely restricted supply, the problem is largely owing to the provision of inefficient or low-value care (estimated by the Institute of Medicine to be at least 30% of care4) and to a bureaucratic and complicated system that is challenging to navigate. Thus, people seek care where it is most accessible, even if it is the wrong place, such as the emergency department for nonemergent problems, or if the care is actually unnecessary, such as much of the care that was provided by online companies. New health care communication technology needs to provide better access and facilitate intelligent triage simultaneously, which will decrease the provision of unnecessary care, freeing the supply to provide high-value care. Second, a recent report fromRock Health points out consumer and economic factors that work against the “Uberification” of health care, includingwhat they describe as health care’s low “virality.”5 Virality is the willingness of consumers to share their experience and expose potentially newusers to thetechnology.Today, traditionalhealthcareorganizations fear patients’TweetsandYelp reviewsbecause theyareoftenaconsequenceofpoor careor abadexperience.There isno reason— beyond the unfortunate metaphor—that health care organizations shouldnot strive forpositivevirality. For example,One Medical Group, a self-proclaimed technology-based primary care practice that incorporates teledermatology and application-based triage, has more than 100000 likes on Facebook, all while adding more than 80000 patients in the last year. Time will tell if such a technology-based practice can deliver consistent, high-quality care. Related article page 635 Quality of Urgent Health Care During Commercial Virtual Visits Original Investigation Research