MARCH 22, 2018 10.1377/hblog20180319.150005
The information revolution has promoted major changes across multiple service industries such as transportation, finance, hospitality, and retail. However, the impact of this revolution in health care has been incremental to date. Nevertheless, there is an evolving debate over and reconsideration of the who, where, when, and how of the entire health care delivery model. This debate has been precipitated by a confluence of events, including the changing demographics of the US workforce, emerging technology, and the march toward value-based reimbursement for health care.
Physicians and other direct-care providers have received insufficient formal training in the application, use, and benefits of the new and evolving technologies that are central to emerging new models of care delivery. In fact, recent calls for the creation of a new “medical virtualist” specialty are now being discussed and will no doubt foster a debate within the profession on the need for yet another specialty. We concur that a new specialty of “virtualists” will emerge to meet the demands of digitally empowered patients in the information age of medicine. And, we anticipate that the training requirements for these clinicians will also receive considerable attention in the coming years.
However, we disagree that the specialty will be solely in the domain of medicine: Virtualist capabilities will increasingly become a requisite capability for teams involving all health care professionals, as health payment systems push toward more value-based care delivery models. Below, we discuss these trends in more detail, and we issue a call to action for the creation of a task force to define the virtualist skills that new virtualist specialists and all health care providers should acquire.
The use of health care teams has been discussed and debated extensively in the literature over the past several decades. The importance of effective collaboration, information sharing, communication, and other factors involved in the “handoffs” of patient care among the various professions has been extensively studied and reported. As noted in the 1995 Pew Health Professions Commission report, there were calls even then for a unifying set of principles to embrace the situation-defined needs and capacities of the team.
Who Are Health Care Virtualists? Why Are They Needed?
Virtualists are clinicians with specific training in the best approaches for managing the care of patients using virtual tools and technologies, either episodically or longitudinally, for individuals or across population cohorts. Just as the hospitalistmovement reshaped inpatient care over the past 20 years, we anticipate the virtualist movement will open new possibilities for directly monitoring, managing, promoting, and restoring the health of patients. The new model will also extend the reach of care delivery to noninstitutionally based environments outside traditional health care settings.
Some argue that telemedicine and telehealth will soon be absorbed into mainstream definitions of “medicine” and “health care,” in keeping with the growing availability and insurance coverage of virtual health services and the changing expectations of patients. As such, elucidation of a unique category of virtualists for all clinicians practicing in the new form of care delivery may be seen as unnecessary. We disagree: While basic virtualist knowledge will become a requirement for all practitioners, there will clearly be a need for virtualist specialists—in the short term—to oversee multiple virtual streams of patient information, and—on a permanent basis—to integrate and interpret these information streams. The important point is that while virtual specialists will evolve, a foundation of training in virtualist care will also become a requisite capability for generalist clinicians similar to other clinical sciences such as internal medicine, pediatrics, and the like.
The capabilities of virtual care will—of necessity—require a team model-of-care delivery. Such an approach will present a de facto requirement of virtualist training for all team members: physicians, nurses, pharmacists, medical social workers, psychologists, nutritionists, physical and occupational therapists, and other clinicians who will have direct contact with patients. Simply having training in one’s chosen profession, in our estimation, will be an insufficient foundation for effectively providing care using virtual technologies.
The current model of disease management relies upon isolated data points resulting from periodic patient interactions, usually derived when patients are either at their sickest, at greatest risk, or at their physician’s care delivery setting during episodic visits. But we anticipate that continuous monitoring of individual patient conditions by a health care team will become the mainstay of managing patients across the spectrum of health states. While automation will eventually minimize the role of physicians and other clinicians in monitoring these data streams, early iterations will require vigilant clinical supervision, to the exclusion of other activities. Over the longer term, the virtualist providers will also no doubt become involved in setting the criteria, establishing the protocols, and defining the guidelines used in the provision of virtual care.
Divining actionable intelligence from these data streams will require analysis and interpretation based on an understanding of the patient’s unique social, environmental, and genetic background, as well as simultaneous consideration of the individual- and population-level factors bearing upon care delivery decisions. Just as the unique intellectual capabilities of many specialties are represented by interpretation of their characteristic unique “squiggly lines” (for example, cardiology and electrocardiograms, neurology and electroencephalograms, and obstetrics and fetal heart monitor tracings), the interpretation and application of population-driven, individually relevant, predictive algorithms will be the defining province of clinical virtualists.
Where And When Will Clinical Virtualists Deliver Their Services?
The widespread adoption of mobile devices and Internet-enabled applications (that is, apps) has altered the consumer landscape across all industries. For example, consumers may now access a wide range of products and services with as little effort as a single keystroke. When well designed and implemented, the experience delights the user. Succumbing to similar pressures, an increasing proportion of health care will be delivered at the convenience of patients, through a variety of channels including apps, self-service kiosks, at-home test kits, and monitoring devices. Clinicians will be deployed to the home and other noninstitutional settings on an as needed instead of scheduled basis.
How will virtualists deliver their services? Industries that have transitioned to the information age have seen their business functions fractured across an increasingly complex network of apps. Take the example of banking, where financial transactions were historically accomplished through face-to-face interactions with trusted advisers housed within a local branch. Now a wide range of services, including check deposits, funds transfers, loan applications, financial advising, and tax planning can be provided for an individual consumer using an array of apps on a smartphone. Ask yourself: When was the last time you were physically in a bank to obtain support or service?
Medicine will witness a similar untethering of care delivery from a specific bricks-and-mortar location and its staff. We project that a patient with multiple chronic diseases, for instance, may soon use a health care team made up of a care coordination nurse, clinical pharmacist, health coach, nutritionist, advanced practice provider, and a primary care physician—all with specific training and education in the use of virtualist tools. These clinicians will interface with the patient and specialists primarily via virtual consults. Such an approach will dramatically reduce the need for venturing to the doctor’s office and dramatically reduce the need for visits to the emergency department. The individuals on a care team may have the same or different employers, but all will collaborate under the direction of the primary care physician—as a team leader—having only their relationship to the patient and a shared data and communications infrastructure in common.
Change Is Already Occurring
In 2012, Kaiser Permanente reported that nearly 50 percent of contacts between patients and primary care providers took place over the phone or through secure emails. Based on recent informal reports at various medical meetings, the rate of virtual provider service at Kaiser now exceeds that percentage by a substantial margin, not only among primary care providers but also among the more digital specialties such as dermatology (personal communication). These trends are likely to accelerate, as reimbursement parity for telemedicineservices is increasing among public and private payers.
Meanwhile, patients are expecting unprecedented levels of access to their providers for even minor complaints; assistance with interpreting data they have personally collected using mobile technologies; and more day-to-day preventive support and guidance outside of the traditional schedule of an annual preventive visit. As a result, we expect that consumers will increasingly demand virtualist capabilities for many of their interactions with the health care enterprise. Therefore, the core elements of virtualist training must be integrated into the training of all clinical providers over the longer term. While some will go on for more intensive training and experience, a foundation must be established for all of the clinical fields in care delivery.
What Training Will Virtualists Require?
As in any specialty, a solid foundation in clinical medicine, nursing, pharmacy, or the clinician’s area of expertise will form the basis of virtualist training. Additional training on the nuances of effective telecommunication use will prepare virtualists to preserve and improve the quality of care delivered through the face-to-face encounters of yesterday. The pace of change is remarkable. Even today, we are quickly moving from the two-dimensional screens of contemporary care visits to the augmented reality and predictive analytic environments of tomorrow.
We anticipate that virtualists will not typically be co-located with patients and other members of the health care team. As a result, their training must emphasize specific competencies related to working in and leading interdisciplinary teams distributed across multiple workspaces and environments. Training in informatics, analytics, and population health will prepare virtualists to separate signal from noise in large dynamic sets of patient data, allowing decisive action without the absolute requirement of the traditional physical examination. However, training will go far beyond the field of informatics to include communications, social media, virtual care dynamics, gamification, and other evolving capabilities based on the use of technology. Although formal training in the above domains will become more prevalent for all medical and clinical specialties as they adapt to the demands of the information age in medicine, deeper competencies in these fields will differentiate virtualists from trainees in other specialties.
Objections to the virtualist model are already on the horizon, just as there were objections to the hospitalist movement in medicine when it was first introduced. For example, a number of state licensure boards continue to require prior face-to-face contact between the patient and the physician before teleservice exchanges are allowed, although these requirements are also changing rather rapidly. Such rules are essentially designed to protect the traditional approach to care delivery.
However, the unrelenting emergence of new and evolving technologies along with the “Internet of Everything” represent dynamic forces changing the fabric of virtually all professions. Instead of resisting change, we believe that medicine—along with the related direct care and healing professions such as nursing and pharmacy—must embrace these challenges as inevitable requirements and capabilities required in the armamentarium of the new virtualist providers.
Several factors will facilitate the emergence of virtualists and the diffusion of virtualist skills across health care. Standardization and interoperability play an important role in realizing the full benefits of virtualist care by providing access to timely, comprehensive, and computable patient data. Health care providers, health information technology vendors, and government regulators must therefore continue to increase the mobility of personal health information, including medical records, to support greater convenience and a focus on the overall patient experience. As health apps move beyond replacing communication channels and into realms such as clinical decision support and monitoring patient status, a new regulatory paradigm, beyond the current model of medical devices, may be necessary to ensure patient safety without unnecessarily stifling innovation.
Harmonization of licensing and credentialing of clinicians across state lines will allow virtualists to fill important gaps in demand for health services in rural and underserved areas, provided that patient well-being and self-regulation by the profession can be preserved. Finally, continued evolution of payment models toward value-based reimbursement will crystallize incentives for delivery systems to provide the most cost-effective care with greatest patient satisfaction. Virtualist clinicians will play a pivotal role under these conditions.
A Call To Action
We propose that the various clinical professions, medicine specialties, and the health professions education community convene a task force to define a consensus on the essential skills, capabilities, and training requirements for the new virtualist model. The health professions must manage the evolutions of these trends, instead of react to them.
Two levels of consensus are required. First, the core content of foundational virtualist training required for all physicians and clinical providers, regardless of their ultimate choice of specialty practice, must be defined. Second, the general requirements for those clinicians who specialize in the field as full-time virtualist providers must also be defined.
The movement has started and will evolve. The professions must now engage and contribute as part of their commitment to society for educating and training physicians and providers of the highest caliber for the delivery of quality care.