Because what happens in the doctor's office is only one piece of the puzzle.
According to the Centers for Disease Control (CDC) and a 2017 RAND report, roughly 60% of the U.S. population is living with at least one chronic condition and 42% are managing multiple chronic conditions. Chronic conditions, including heart disease, stroke, cancer, and diabetes, are the leading causes of death and disability. Although entirely preventable, these conditions contribute to 90% of the nation’s $4.1 trillion in annual health care expenditures. As the incidence and cost of chronic conditions continue to increase, the personal and economic tolls necessitate the implementation of improved solutions for primary care physicians to manage these conditions and decrease health care costs.
Chronic conditions are a challenge to manage within the confines of the current episodic care model, where a patient is seen for 15 minutes in an office visit a few times a year. Effective management of these chronic conditions instead requires real-time, continuous monitoring and increased patient-provider touchpoints and engagement. Digital health technologies such as intelligent support for analytics and decision-making, wearable sensors, remote patient monitoring (RPM), and patient-facing apps are promising innovations which can help primary care physicians optimize patient outcomes, improve quality, and decrease health care costs. And according to a recent AMA report, physicians are increasingly on board: Two in five physicians plan to adopt emerging digital health technologies in the next year and nearly three in five believe technology can help in key areas such as chronic condition treatment and preventive care. This increased adoption of digital health technology can improve chronic condition care management and prevention going forward, and ultimately, help reduce the trillions of dollars spent annually on treating these conditions.
When it comes to managing chronic conditions, what happens in the doctor’s office is only one piece of the puzzle. Managing a chronic condition can be a decades-long or lifelong commitment. When patients only see their primary care physician once or twice a year with minimal communication between in-person visits, conditions can progress unknowingly and opportunities for intervention are missed. Infrequent patient-physician engagement leads to poorer health outcomes as patients may be less likely to adhere to their treatment plans and make long-term lifestyle changes, and physicians don’t have all the information needed to optimize treatment.
Instead of just trying to manage individual patients in the office visit, primary care needs to figure out how to monitor their entire patient population and then identify and intervene with the appropriate patient at the right time, before their disease has escalated. This is important for those providers who are in traditional fee-for-service (FFS) as well as those increasingly participating in value-based care and risk-sharing agreements. The challenge is how to improve work efficiency and provide this type of care model at scale despite the current strains on resources being experienced by all providers and practices.
Innovations in digital health, such as artificial intelligence (AI)-enabled data insights, telehealth appointments, remote asynchronous care, and virtual patient facing resources can help patients stay engaged in between visits or when going to see their providers in person isn’t an option. Digital health tools and virtual care programs also help primary care physicians and care teams better collect, monitor, and act upon patient health data to make real-time changes to treatment plans based on consistent monitoring and results. For cardiovascular patients, for example, digital health tools may include at-home monitoring devices (blood pressure cuffs, heart rate monitors, weight scale etc.), medication and lab guidance, and personalized titration plans to get patients to target therapies and goals. These technologies and programs help to optimize treatment and streamline communication between physicians, patients, care teams, and caregivers, and have been implemented with great success by health systems and cardiology practices across the country.
While digital health adoption and successes in this arena are increasing, it can be difficult for providers seeking these tools to identify the best solutions and programs to implement as the health information technology (HIT) market grows saturated. One challenge is that many digital health tools only address a portion of a problem and do not provide an end-to-end solution for a patient's chronic condition. RPM alone, for example, is not useful without appropriate insights on the data and the ability to quickly take appropriate actions if needed, all without placing undue burden on the clinical team.
Additionally, for a digital health solution to be both effective and efficient it is critical that it integrates seamlessly into the existing clinical workflows. Integration into the electronic health record (EHR) is key to ease-of-use and physician engagement, as it prevents siloed data and allows patients’ care teams to develop more holistic, optimized care plans that incorporate EHR data along with information from the home and outside the health system. Digital health technologies that don’t have EHR integration or that funnel data into the EHR in unstructured, incoherent lump sets can create more work than value for physicians and providers, requiring them to wade through and synthesize disparate sets of patient health data. This takes up valuable time that could be spent with patients or on optimizing treatment plans. As a result, in the end, tools without appropriate integration have low utilization and do little to impact care. When deciding what digital health tools to implement, decision-makers should consider scalability, versatility, ease-of-use, and data integration capabilities as important factors.
Digital health solutions and virtual care programs are vital in augmenting the reach of our primary care physicians, specialists, and care teams. Notably, as health care staffing shortages continue to impact health care access for patients, digital health and AI-enabled capabilities can make care more scalable, accessible, and personalized by allowing physicians to tailor treatment plans to each patient’s unique needs, medical history, and social determinants of health. Innovations such as virtual health coaching and patient-facing apps enhance the empathetic human touch of health care by making care management a higher-touch experience for patients and helping them feel more engaged and informed throughout their care journeys. This can be especially critical for patients with chronic conditions, as managing symptoms and long-term treatment can be complex, emotionally taxing, and overwhelming.
Digital health doesn’t have to replace in-person doctor’s visits altogether. Rather, it is most effective when used in conjunction with in-person visits to collect and analyze patient health data consistently, and respond to patients’ needs in real time, giving patients needed support and ultimately optimizing health outcomes. As we look toward the future of health care and chronic condition management, we have the unprecedented opportunity to leverage digital innovations such as AI, remote care, and patient engagement apps to improve population health at scale and bring timely, high-quality care to the patients who need it most.
Ashul Govil, MD, MBA, is cofounder and chief medical officer of Story Health, where he oversees all medical and clinical aspects of the company’s products and services. A practicing board-certified cardiologist in the San Francisco Bay area, Dr. Govil has spent years caring for heart patients, and that experience has given him a front row seat to the gaps that exist in the health care system. Follow Dr. Govil on LinkedIn and Twitter @ashul