Brad McCarty • April 4, 2018

Dr. Michael Hodgkins has more than 25 years in health services, clinical connectivity, and in e-business solutions. As the Chief Medical Information Officer of the American Medical Association (AMA), he provides leadership and expertise in developing new products and services, as well as the AMA’s strategy for digital health, medicine, and IT policy.

We were honored to host Dr. Hodgkins at the Alpha Conference in January of 2018. In his talk, he focused on the importance of the physician having a seat at the innovation table. While this might seem obvious at first, his reasoning should give you a number of subjects to consider.

Including physicians in the discussions, or in some cases even having them lead the talk, accomplishes fouor significant goals:

  • Maintaining the value of the patient/physician relationship
  • Managing physician burnout
  • Avoiding “digital snake oil”
  • Managing chronic disease in the wild

His entire talk is worth a listen, but pay special attention to the four questions that every physician should ask when discussing innovation. These are points that we aim to solve with AngelMD, and having a core of physicians in our network enables this to happen.

Read more about evidence-based investing through AngelMD.

The subject of this talk in your pamphlet is, the physician’s seat at the innovation table. Who here in this room does not think that physicians need to have a seat at the innovation table? Raise your hands if you’re brave enough. Okay, well my job here is done thank you very much.

In the AMA, our focus has been primarily in the digital health, digital medicine, connected health, M health, whatever name you want to apply to it. It has not been in the device or pharma phase, but as my colleague from the American College of Cardiology mentioned earlier, the lines are blurring between the device space, the pharma space and the so-called digital health space. In pharma, they like to talk about surrounding the pill, you probably have heard that phrase. Sometimes that’s just content, educational content, but increasingly, they want to surround the pill with apps and information exchange and sharing between the consumer and the pharma company, as well as with the physician.

We’re seeing a merging of these two areas, but each has their purpose and value. At the AMA, without the benefit of slides, some of the themes that we’re focused on when we talk about involving the physician at the innovation table, especially in the digital health space, are few.

One that was mentioned by Dr. Lynn, is the physician patient relationship. There is a therapeutic value to the physician patient relationship. It may not be more than 10 or 15 percent of the ultimate contribution to outcomes for patients, but I think most physicians would acknowledge that there is a therapeutic benefit to that relationship. That relationship is not gonna be displace by your smart phone. You’re not going to declare your smart phone your primary care provide anytime soon, and hopefully never.

Another area that we’re very focused on when we think about bringing physicians in the discussion, is the question of physician burn out. That’s something I’ll elaborate on more as we go forward.

A third area is digital snake oil. Some people probably recall about two years ago, Jim Madara, our CEO used the phrase, “the digital snake oil of the 21st century”. He was using that reference because one of the first things the AMA did back in the 1800’s was to root out the snake oil business and people who were peddling themselves a healthcare professionals, if you will, at that time, who had no business doing that. Jim was terribly misquoted, taken out of context, because he prefaced his comments up to the point of talking about digital snake oil by talking about all the fantastic things that were happening in the device space, radiation therapy, robotics, biologics and so forth. What he simply said is, look there’s also a lot of junk out there that has no scientific basis, there’s no evidence, there’s no proof of value. All it does is cause confusion and distraction and wastes people’s time. That’s when he concluded, by saying it was the digital snake oil of the 21st century.

We’re getting any slides or not?

The last areas where we’re focused, is on an issue that I brought up during the panel, and that is the predicate that I believe very strongly in, but I’d be curious if anyone would argue the point, that in an age of chronic disease, the notion that you’re gonna manage the patient’s care through the clinic alone is ridiculous.

I’m an internist by training, so interns see a lot of hypertension patients. I would diligently bring back my patients with hypertension after I thought I stabilized them on medication, depending on what other co-morbidities they had, I might see them every couple of months, few months, six months, whatever. They’d come to the clinic, they’d get one blood pressure measurement by an MA or a nurse. I was also someone who wanted to measure the blood pressure myself, so that was two measurements at different times of the day, in different circumstances for the patient, who knows what happened to them leading up to their arrival in the clinic.

On the basis of that, I’d make treatment decision. I’d adjust medication, I’d add medication. I’d remove medication. Who was I kidding? That’s why 50% or more of the patients with known hypertension who are under treatment aren’t managed successfully. Because, what happens to the patient out in the real world with a chronic disease is more important than what happens in the 15 minutes that they’re in the clinic.

We know that this digital health landscape is very complicated. This is an illustration of that, but we put the doctor and the patient at the middle of the conversation, in terms of, how do we make that work in this digital world, in this virtual world.
These are the themes that I was talking about earlier, somewhat more illustrative perhaps, in terms of talking about burnout. The picture on your far left, I think was from the New York Times, “No, you cannot declare your smartphone to be your primary care provider for the health plan.”

Moving beyond these themes, if you’re gonna bring the physician to the table and make them part of the discussion, you ought to listen to what they have to say and see where they are currently in their thinking. What attracts them to the use of these tools and what are their expectations and requirements? This is one of those glass half empty or glass half full slides, it just depends on your temperament.

What we found that drove physicians interest in these tool, and we surveyed them in terms of several modalities that you see listed here, was that they thought they could do a better job of taking care of their patients. That was the most compelling reason for their interest. I think related contributions, their interest was, they thought they might be able to do it more efficiently and effectively than they’re doing it today, especially with their EHR’s.

As you can see, we’re talking about a level of enthusiasm of about … approaching 50%. Is the glass half empty or glass half filled? I think the more important thing is the level of adoption. If you’re looking at consumer portals, which to me are sort of ho-hum, the levels of adoption there are pretty high, but nobody really thinks that they contribute that much value. If you look down on the left though, in terms of virtual visits, remote monitoring and so forth, the things that we really expect to have a true impact on the care that we deliver and the cost of care going forward, levels of adoption are still pretty low. We haven’t crossed the chasm in regard to those tools.

What did physicians want to know, or what did they expect in order to adopt these tools? There are really four questions that came forward. One, does it work? Is it evidence based? Is there any science that demonstrates the value of this tool? A reasonable thing to ask and a thing that most physicians would be concerned about.

Second question was, will I get paid? Reimbursement is an issue. We’re still living in a fee for service world and even in a value based world, you have to decide on, is there gonna be an economic benefit to the use of these tools versus traditional practice.

Will I get sued? This wasn’t just medical malpractice, this is concerns about HIPPA privacy rules and the like, data breeches and what have you. Are these digital tools gonna expose me to more liability in regard to the current work environment?

Lastly, most importantly is, yes there’s good science, yes I’ll get paid, no I won’t get sued, but will it work in my practice? Will it actually fit into the work flow that I have with my team in my practice? Let’s remember that most physicians, about 50% of physicians still operate in configurations of 12 or fewer physician FT’s. Everyone looks at the enterprise, the big hospital systems and what have you, you think you can solve it there then you can easily solve it here. Well you can’t, because there’s no leverage. You don’t have the resources in a 10 or 12 physician practice that you do in a large enterprise. Work flow is a huge issue, and a number of people brought that up through out the conference.

The last thing that came through in this survey, which was published in September of 2016, if you want to access the full survey data you can go to the AMA website, was that physicians wanted to be part of the decision process. They wanted to be heard. Frankly, they thought that they hadn’t been heard for many years, especially with the implementation of the electronic health record.
What’s getting in the way? Earlier on the panel we talked about the regulatory environment, we talked about legal issues, we talked about payment issues, but for the moment, what I’d like to emphasize is the issue of physician burnout. Has anybody not heard of the term burnout? Anybody not heard that? Okay.

Let’s talk about it. Physicians, by a number of recent studies, are spending twice as much time working in their EHR and on other desk work as they are in patient care. Even when they’re with their patient, they’re spending more time looking at a computer screen than they are interacting with their patient. Then you have the issue of what people call pajama time. The physicians are spending almost 40 hours a week, after clinic, playing in their EHRs to catch up with documentation. This increase in physician burn out, somebody actually did the math, between 2011, 2014, led to a 1% reduction in productivity, was equivalent to the loss of the graduating classes of seven medical schools.

Just think about that. We have a huge problem with availability of physicians and access, the whole workforce issue, and yet look at what we’re doing to physicians, and reducing their productivity.

Now, the shift in value based care, a lot of people say that’ll take care of the problem. Maybe it will, but I think we still have fee for service in about 67% of care delivery today, so I don’t know that we can wait on that solution.
This is an interesting chart too, that shows, if you can see by specialty, the increase in physicians reporting symptoms of burnout between 2011, 2014. More than half of physicians in this country today are reporting some aspect of burnout, more than half. Compare that to the general population. The general population statistics around burnout are only about 24%. For physicians, symptoms of burnout are twice as much as the general population.

Who cares? We’re physician’s we’re tough. We work hard, we know we work hard, we’ve got a challenging job, so what? So what is, there’s about a dozen CEO’s of prominent healthcare systems in this country who got together last spring at the AMA to talk about this issue. Afterwards, they wrote a blog that they all put their names on, and the blog began by describing burnout as a public health crisis. Why? Why a public health crisis? Because burnout is associate with bad outcomes, with patient safety issues, with deterioration in the workforce. These CEO’s actually said that they believed that a physician leaving practice because of burnout, cost them 500 thousand to 750 thousand dollars, just in terms of replacement cost and issues associated with that physician leaving as a result of burn out. That’s why it’s important.

Then you have the proliferation of mobile health apps. 200 thousand is now probably well shy of what’s out there. Even if you whittle away the wellness health apps and narrow it down to the 30 or 40 thousand apps that are actually supposed to help patients better manage chronic diseases in conjunction with their healthcare team, how do you navigate that? How do you know what’s good, what’s not good? Then there’s the fear of a tsunami of new data.

Physicians already feel like they’re awash in the data in their EHRs, Dr. Lynn said, can’t make any sense out of it anyway. Can you imagine somebody monitoring their blood pressure and somehow transmitting thousands of blood pressure measurements to you? What do you do with that information? Obviously you can’t absorb that, you don’t want to absorb that. That’s not the right thing. Somebody has to be intelligent enough to process this information before it gets to you, so that it’s actionable. Especially given the experience with EHR, if physicians aren’t in the forefront discussing these issues with the entrepreneurs who are developing these solutions, then we’re gonna repeat history.

This was the snake oil versus useful tools in patient care. There’s actually increasing evidence that things like remote monitoring are gonna make important contributions to the care of patients. What’s been missing from the equation though, is any kind of metric analysis. We still haven’t caught up with understanding what the cost and value associated with these things are, what the return on investment will be? Are they really better than standard care?

Let’s keep in mind what happens when physicians are not involved in the process. There’s two apps that are referenced here, the one on my right, your left, was the top selling blood pressure app in the Apple store. It was downloaded over 100 thousand times. It purported to allow a patient to measure their blood pressure by holding the microphone up to their chest … I think you had to put your finger on the camera … this is real. There was actually a study published in JAMA to evaluate the accuracy of this app. Eight out of ten times it was wrong, and most often it told patients with hypertension that they had normal blood pressure. That app stayed in the store until the Federal Trade Commission got involved and made them removed it because they were making false claims.

The other app was Dr. Mull. Dr. Mull said you could take a picture with your smartphone of a skin lesion, and it would tell you if you had cancer. Didn’t work. Also, ultimately the FTC intervened, said they were making false claims and have it removed. Those are just two apps out of tens of thousands. How many people here think that’s an anomaly? I don’t. I think it’s just the tip of the iceberg in terms of safety and effectiveness for patients.
What are some of things that we’re doing to get physician’s more involved? One of the main things that we’re doing is something called a physician innovation network. The physician innovation network was actually largely in beta through most of 2017, but it was launched in version 2.0 in October of last year. Before the end of the year, we’d amassed over two thousand users, more than 14 hundred of them physicians. There were a thousand connection requests between physicians and entrepreneurs, number of saved opportunities. We’ve been working very closely with a number of accelerators and the Society for Physician Entrepreneurs to gain interest.
What is Physician Innovation Network? It’s match.com for physicians and entrepreneurs. It doesn’t cost anything for an entrepreneur to register on the site, doesn’t cost anything for a physician to register on the site. You create a profile of your background, your interests. As the entrepreneur, what kind of physician’s you’re looking for by specialty, by age, by practice type, whatever it maybe, and we match you up and you take it from there in terms of having conversations that are gonna be meaningful to you as an entrepreneur.

For the Angel MD folks in the room, you’ve got a platform that does some similar things, so there’s actually some interest on both our parts in exploring that further.

We’ve had tremendous reaction to this in the trade journals since it’s inception, lot of excitement’s been generated. This year, we really hope to scale that tremendously. Our goal is to have ten thousand physicians from a variety of practice types and specialties and age groups and what have you, enrolled in this in the coming couple of years, and a large number of entrepreneurs. Again, we’re not trying to make any money off of this, we just want to make it possible for physicians to interact with entrepreneurs without having to think of making the binary choice of, I stay in practice I ignore what’s happening in the technology space, or I leave practice and join a start up. That shouldn’t be the only decisions that physicians can make.

Then lastly, to further involve physicians in the conversation with entrepreneurs and innovators, we’ve developed a number of other relationships. I mentioned Smart Health, earlier on the panel. We actually participate in their board helping provide physician perspective. The Sequoia project is the evolution of the E Heath exchange. It represents the largest information exchange network in the country today. I sit on their board, the AMA is an active participant and founder. Exertia was something that we announced last year. It’s a new non-profit that the AMA is a founder of, along with three other organizations, Hins, being one of them, the American Heart Association being another.

Exertia is actually publishing guidelines for what constitutes good mobile health applications, not only in terms of privacy and security and [intereoperability 00:20:03] but in terms of clinical evidence and usability in clinical practice.

I also mentioned earlier today, Health 2047, our innovation lab in Silicon Valley, which the AMA works very closely with, even though it’s an independent organization. That’s all I had to say, but I think I’ve got time for maybe one or two questions if anybody has any.

Yes sir.

Speaker 2: You referenced the statistics where doctors are spending more and more time with a computer. There was a time there weren’t computers, they were writing on charts.

Dr. Hodgkins: Sure.

Speaker 2: So, two part question, one is, how does that compare with when we had paper charts versus EHRs. And, are doctors now seeing more patients per work day or per unit of time, and as a result spending more time documenting?

Dr. Hodgkins: The statistics show that physicians are seeing fewer patients with the electronic record, per day, than they did with paper records. That can change over time, but it can take six months to a year to return to a similar level of productivity. In some cases it extends beyond that. I think the difference in the paper record was something that was mentioned earlier today by our colleague from DARPA, and that is, what did you do in a paper chart? You weren’t checking a lot of boxes, you weren’t pulling down a lot of menus to code and what have you. The EHR really is enslaved to the billing process. The way we use the paper record was to capture a narrative. That narrative could be just a paragraph, but it communicated a lot of value, especially to another physician who might have to see that patient that had no familiarity with them. In today’s electronic health record, trying to reassemble the equivalent of that narrative is virtually impossible.

Any other questions?

Speaker 2: Could you tell us about the … get this right … another initiative … oh thank. Another initiative is the integrated health model initiative from the AMA, could you tell us about that please?

Dr. Hodgkins: Well, we don’t have a lot of time for that, but we just announced this towards the end of last year. The integrated health model initiative is an effort on the part of the AMA to create a master coding data model, or a specification for a data model that takes existing coding systems, like ICD, CPT, [Snowbed 00:22:47] and others, aligns them, but fills in the gaps. Where are the gaps? Somebody mentioned this earlier today.

All of our coding systems today are about, how do you capture a profile of a sick patient? None of our coding systems today help you capture a profile of a well patient. It’s confusing to me that, if you don’t have a baseline of wellness to compare to, how do you know what you’ve done for the patient, that sick patient? Have you returned them to a state that they previously enjoyed, that they are interested in or not?

My colleague often brings up the example of people who have cataract surgery. The cataract surgeon measure success in terms of the visual acuity achieved at the end of surgery. The patient may measure success in terms of whether they can drive at night any more. But we don’t capture that information. This whole idea of patient contributed information, it’s a wonderful idea, we all talk about it, but we have no standard vocabulary for capturing that information. The integrated health model initiative is an attempt to develop that. You’re welcome.

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