Random Considerations - 5/1/18

Observations, Books or Articles worth a Thought or Two…

A Buzz To Remember – The brewing controversy over the response of Facebook to a number of issues but primarily related to its position on the use of personal information by the more than 2 billion users is not an incident but a growing cacophony.  It wasn’t helped this past week by a piece in Buzz Feed on the role of Vice President Andrew Bosworth – a provocative Vice President for consumer hardware – when it was revealed that in an internal post back in 2016 he wrote the following:  “The ugly truth is that we believe in connecting people so deeply that anything that allows us to connect more people more often is *de facto* good. It is perhaps the only area where the metrics do tell the true story as far as we are concernedThat isn’t something we are doing for ourselves. Or for our stock price (ha!). It is literally just what we do. We connect people. Period.” You must read the whole article to get a sense of the issue and how the use of data and information by Facebook has not only created wealth but also now consternation among many on their team. 

Change Happens When You’re Not Looking – I feel like I’ve been hiding under a rock or something.  This past week, I attended the American Telemedicine Association conference – one of my favorite annual treks.  This year the meeting was held in Chicago at McCormick Place but the important point is that the other ongoing event at the same venue was America’s Beauty Show!  Yes, America’s Beauty Show.  It was a lesson in “changeor, “what happens when you’re not paying attention”.  I have never seen so much blue (I mean really blue), green, pink, red, yellow, fuchsia and other assorted colors of hair!!  Not only that, but many of the people (mostly women – not a statement, just an observation) were wearing jeans with frayed fronts and/or holes – something we would have patched over in the 1960s with an upside down flag or something.  I felt like what was normal had been turned upside down.  Shouldn’t colored hair be natural and subdued rather than bold, if not outrageous, and iridescent?

Now………..imagine how the medical and health care community feels when we tell them that a lot of their thinking will be replaced by artificial intelligence, that robots are coming which can actually interact with people, that the way to increased productivity is through the use of remote care management monitoring devices and on and on.  Imagine you grew up when the Beatles and Rolling Stones were popular and now there is some weird kind of music you can’t figure out.  That’s called “change” and, it happens.  If you think you’ve seen a lot of change in health care over the last decade think blue (I mean really blue), green, pink, red, yellow, fuchsia and other assorted colors as the metaphor for what’s happening.  It will help you to understand how much change is coming.  And, it won’t take five decades…

What Higher Ed Can Learn from Healthcare

You can click here to listen to the podcast, or read below.

Southern New Hampshire University
Office of the President
1230 Elm St, Manchester, NH 03101
December 2017

What Higher Ed Can Learn from Healthcare? - Transcript of Podcast Interview with Kevin Fickenscher
The following is an edited and adapted transcript of this episode.
Brian Fleming:
Hello, everybody, and thank you for listening to this episode of Thinking Outside the Sandbox. My name is Brian Fleming, executive director for the Sandbox here at SNHU, and today we have the privilege of sitting down with Kevin Fickenscher, president and CEO of CREO Solutions, a consulting firm that focuses on leadership and strategy. Kevin, thank you so much for connecting with us and taking the time to talk.
Kevin Fickenscher:
My pleasure to be with you.
Brian:
Kevin, before we jump into some more specific questions, can you tell us a bit about your background and what is CREO Solutions? What kind of work do you all do?
Kevin:
I'm a family physician originally, and I practiced for about a decade back in North Dakota where I grew up. That's where I first got interested in the use of technology for delivering health care services. I then moved into more mainstream management. I was the chief medical officer for a couple of the largest health care systems in the country, one of which was Dignity Healthcare on the West Coast. I was there during the period of the dot-com era, and I had dot-com fever like everybody who lived in San Francisco. I started my own little company, which became a part of another company that merged in with WebMD. I ended up being the chief medical officer for WebMD, which is what took me into the technology field.
From there, I worked in consulting, worked for Ross Perot for a long time. I led his consulting practice. I was the lead for international health care and lived in London, took us into the Middle East, China, India, etc. And then returned home about a decade ago when Barack Obama was elected president and have beendoing consulting and a variety of work related to the use of technology in actually delivering care. I refer to it as telecare because it's actually using the technology to deliver care. I've also been involved in leadership development and strategy work for health care systems.
Brian:
In health care, just like any industry, there has been a "digital revolution," new tools and technologies that have continued to disrupt and change and challenge the industry. Could you talk to us of your observations as you have seen health care continue to go increasingly digital?
Kevin:
I really do fundamentally believe that we're at a very interesting point in the history of mankind. If we think back about all the changes that have occurred in society, we had the Neolithic period that occurred about 15,000 - 20,000 years ago. It lasted for several thousand years. It moved us from being nomadic peoples into being tribal and setting up communities. We then had the industrial revolution, which really moved us from an agrarian society to more of an urban society. And now we have the information revolution, which is upon us, and it's fundamentally changing the whole notion of how, where and who delivers all sorts of services. It's affected literally every industry, manufacturing, logistics, news, media, travel, aviation and it hasn't affected health care in the same way, but it is on the cusp of doing that.
By the way, I should point out the Neolithic period occurred over several millennia. The industrial revolution occurred over a couple of centuries. The information revolution is going to occur over a period of maybe 20 - 30 years. We're in the latter part of that revolution, from my perspective. And so, over the coming decade, I think we're going to see some very dramatic changes in how health care is delivered, who is delivering it, and the tools that are going to be used in supporting it.
Brian:
Just to focus the conversation for a moment on education, imagine yourself talking to education leaders who have had very little engagement outside of our own industry, what do you think is important for us to understand about trends and innovations in health care particularly around digital?
Kevin:
I'm very involved in the education front, as well. I sit on the board of directors of Fielding Graduate University, which is one of the first universities to engage in a more virtual education. We're very cognizant of that issue. As a matter of fact, one of the things that I believe is happening in the education field, along with health care, is that we're the two industries that have sort of lagged behind other industries in terms of changes. I think that education is going to face the same issues.
One of the examples that I use is that I know for a fact that there is some person going to medical school, probably in Africa, who's not going to medical school. What I mean by that is literally the entire curriculum for any number of medical schools is available online. As a very energetic individual, I could go online, I could look at that curriculum, I could find all of the materials to support the education in either anatomy, physiology, chemistry, microbiology, etc, and I could start to go to medical school. The part that I might be missing is the clinical experience, but I would have a lot of the basic sciences available to me online.
The whole notion that you have to go to a place to get your education I think is changing, number one. The whole notion that it's going to be some professor that is trying to get his Nobel Prize is going to be your teacher is changing. I think our whole notion of what it means to be educated is changing. I would also argue that in the world that we're facing that education is not a static experience. It's not something that we get, and we have a degree and that's it. It is very much a continuous process. I know that as a physician, trying to keep up in the literature with the latest ideas, the latest changes, the latest revelations that have occurred is extremely difficult, and I think that applies to education, as well. I think, from my perspective at least, we're undergoing a very dramatic shift in how, where and who is going to be delivering education services as much as health care.
Brian:
When we think about that shift, I think that puts new pressures on higher education to think about itself perhaps in ways that it hasn't. How have you seen that happen within health care? Can you try to help us understand what some of that shift looks like from the health care side, as well?
Kevin:
Well, let's look at it first of all from the standpoint of the patient, and then let's look at it from the standpoint of the profession. From the patient's side, if we ratchet back 30 years, literally the way a patient was cared for is that they had to physically go to a place generally called a clinic or a hospital or an emergency room. They had to be seen by the people that were there to take care of them, the nurses, the pharmacists, the physicians, etc. And they were evaluated. All sorts of tests were done. Data was gathered, frequently on paper, and that was put together. A lot of times some of the data was missing when it came time for the physician to look at the information, but we did a pretty good job and we managed care and people got better as we took care of them.
Now, ratchet forward 30 years and I can tell you that, for example, if we take the problem of congestive heart failure, which is the most common admission into a hospital in the United States, that literally there are four stages of congestive heart failure. There's stage one, two, three and four. For literally stages one and two, I can manage those problems at home. They don't need to come to the clinic. They don't need to come to the ER or the hospital.
How do I do that? Well, every morning when a patient gets up, they step on a scale, they step off. When they step off, the data goes into a computer system in the cloud. They then take a little device about the size of quarter, maybe three time thicker than a quarter, they squeeze it, they hold it for 10 seconds. As a result of that, we get a one-lead EKG, we get an oxygen saturation level, and we get a pulse. There's now a new device that you put on the chest that's like a Band-Aid and it gathers electrolytes. Electrolytes are like your potassium, your sodium, your carbon dioxide levels, etc. With that information, I can basically manage stage one and two congestive heart failure. I know when people are getting worse as a result of looking at those parameters, and then talking with the individual over the phone. That is a radically different approach than what we did 30 years ago where those people ended up coming into the hospital, being taken care of, etc.
In the same manner, the professions have also been challenged in that the question becomes who can provide that service? If we have tools, I refer to them as clinically augmented intelligence tools, computers, that provide guidance and help us ferret information and go through the protocols and say, "This particular patient really, given their history, is more at risk of going into stage three than another person. Therefore, we need to be more aggressive in our treatment. Let's send out the home health nurse to do a physical visit." But it's a home health nurse going out to the home to do a visit rather than trying to drag the patient into the clinic to see a physician, and then having that home health nurse interact with the physician. So who's delivering the care is changing.
Now, as a result of that, we're seeing changes in the professions and the challenges. Much of the discussion in health care is around the notion of how do we get people to practice at the top of their license, in other words at their maximum capability? It’s very clear that a nurse practitioner using guidelines and protocols can perform about 90% of what a family physician does. It's the 10% is the difference between a nurse practitioner and a family physician. That is a margin that's getting smaller and smaller. Those are some of the challenges that we face. I think on the personal side, there's an increasing expectation of being able to give services in the home, in the environment that they want. Then, on the professional side, we're seeing a change in the pressures, if you will, or the challenges, if you will, of what it means to be a doctor, to be a nurse, to be a nurse practitioner, etc. I would imagine that the same thing applies to education, as well.
I was talking with a young woman that I go to church with and she's enrolled in her PhD program on a virtual basis. She's studying ecology. She did all this search. She decided that she didn't want to move from Maine and she enrolled in her program and she's very happy. She's studying turtles and all sorts of interesting things. That wouldn't have been possible even 10 years ago. The question is who is involved in teaching her about turtles? She's finding professors all over the country that are involved in performing that. She's doing her education on a virtual basis, but she's reaching out to other people who can also help her with her PhD thesis, as an example.
Brian:
Along those lines, I think there's also now this emerging space of using AR and VR and IOT sensors, etc. What are you seeing happening around some of these more cutting edge, almost futurist types of tools and technologies?
Kevin:
Sure. Let me give an example. I've done some work with MITRE Corporation, which is a company that provides research services to the federal government. One of the projects that they were involved in is a project for the Veterans Administration where over the course of 18 months we captured the data of experts in PTSD, post-traumatic stress syndrome, and individuals who had PTSD. By capturing that audio information only, we were able to teach the computer how to diagnose PTSD as well as the experts with a 95% concurrence rate. What that means is that the computer was as effective, essentially, as the experts, which means that they were far better than a general practitioner out in the field. The computer is better at diagnosing PTSD than just your average person who doesn't have much experience in working in the field.
What was interesting is that the computer actually got better at predicting those individuals that were at risk of committing suicide, which is a very powerful tool. That's the kind of tool that I refer to as a clinically augmented intelligence tool. It is a tool that really says, "Hey, Dr. Fickenscher, based on the audio conversations, have you thought about depression on this patient? Have you thought about early stage Parkinson's disease?" There's any number of problems that could be cued up, if you will, by audio.
Adding that kind of skill or that kind of capability to things like virtual reality I think is very exciting, but I think we're at the very formative stages of things like virtual reality. It's just coming to the forefront now, and how that is going to be used I don't think we have a lot of clarity at this point. There's a lot of experimentation with the tool, but I don't think that it's actually being used in clinical settings at this point.
Brian:
I know in higher ed we're familiar with a lot of these emerging technologies I think that there's a growing sentiment within higher ed that we are to look to other industries like health care to see how the tools are used.
Kevin:
Can I just jump in on that, Brian.
Kevin:
I think that every university should have a cohort of people whose function it is to be constantly surveilling the environment on the technologies that could potentially affect their approach towards education. That is an essential function. Now, I don't necessarily believe that has to be done by each university on its own. I actually believe it would be better if a couple of like-minded universities got together and said, "We're going to create a collaborative to do this environmental scanning." And the reason I suggest that as a strategic initiative is that innovation in technology is changing so very rapidly that it's really hard to keep up. Assigning four or five people to the project is insufficient to keep track of all of the changes that are occurring in the technology front. I just wanted to put that in. 
Brian:
That raises a question that I think a lot of educators ask and is on the skills side, what is the world that we're training our students for? If we think about students that are going into health care, medicine and allied health, etc, but I think just more broadly as we think about a world where these technologies such as AR and VR and augmented intelligence are more prevalent, what should we be doing and where are there potentially gaps in our current education and training model?
Kevin:
Well, I think that at the outset, from a foundational standpoint, we need to be teaching people to be continuous learners. I have to say, at least in my personal experience, I don't think that was necessarily the focus of my education historically. Now, maybe things have changed in universities, but I don't think so. A lot of the focus is around the endpoint of getting a degree, completing a thesis. These are endpoints and they're sort of like, "Oh, I did it." Well, no, you're just starting, would be my argument. So continuous learning and learning how to learn continuously and learning how to sift through the plethora of information that is becoming available and trying to figure out. For example, given all the stuff that we've experienced over the last couple years with the internet and the reliability of information that's out there, how does one sift through that information? How does one make a determination on whether on some piece of information is accurate or not? Those are the critical kinds of skills that are going to be important.
I would also argue, at least in the health care space, that we need to be thinking about how do we train and support people to become what I call health care virtualists? What I mean by that is somebody that doesn't necessarily physically touch the patient, but is looking at data about the patient, is probably talking to the patient, is looking at physiologic parameters of the patient and having a totally different interaction with an individual on a virtual basis. I would argue that it takes a different set of skills, a different set of sensitivities, a different sieve, if you will, of looking at the data to be a good virtualist than it does to be somebody sitting in a room with a patient.
Brian:
One of the natural questions that often comes up is does this signal a loss of jobs? Does this signal a gain in jobs? I think a lot of the research that I've seen suggests that in this new era of digital and virtual, there will in fact be more jobs. It's just that the skills and the competencies needed to do those jobs change.
Kevin:
Absolutely.
Brian:
Are the robots eating everybody's jobs or are they just changing our jobs?
Kevin:
Oh, I just think they're changing our jobs. As a matter of fact, I was on a panel here a couple weeks ago and I made a fairly provocative statement. I said that family physicians, if they don't embrace the changes that are occurring around things like virtualist care, the family physicians will become the coal miners of health care in the next decade. What I meant by that is that I think it's disingenuous to suggest that coal mining is going to come back, from my perspective. Rather, what we need to be doing is taking those individuals and giving them new skills, new knowledge, new capabilities, new talents, new professions. That's part of what I think is going to be occurring. I think we're going to see a dramatic increase to the number of jobs because mining data is actually more difficult, in some respects, than mining physical coal, as an example.
Brian:
Along those lines, is what is your recommendation for education circles? What do we do about this? What is our mandate moving forward?
Kevin:
I think that there is a need for universities to move beyond the physical parameters of their institutions and start to think about how they could collaborate with other like-minded institutions, because the sum is greater than the parts would be my argument. That's one. I also think we need to be rethinking how we even educate our educators, along the lines of what I was talking about with the virtualist health care providers. What about the virtualist educators? I think it takes a certain new set of skills, a new set of capabilities to be able to be an effective teacher of students on a virtual basis. And yet, I don't think there's that much focus on that aspect in higher education, at least I haven't seen it.
I do believe, also, for example there are a lot of very interesting higher education institutions particularly at the undergraduate level that have provided very innovative undergraduate educational experiences for their students. I'm thinking of some of the small colleges. And they're really struggling. I think they need to think about how they can come together and figure out how they can reduce their cost by sharing some of the back-end capabilities so that the front end is sustained and is stronger.
Brian:
As a final question, and we ask this often with folks on this podcast, as you look out to the future are you hopeful? Are you optimistic? Are you concerned? What are your thoughts?
Kevin:
When I was admitted to medical school, one of the requirements at the University of North Dakota Medical School is that everybody was required to take the MMPI, the Minnesota Multiphasic Inventory. I remember at the admissions committee when we were being asked our questions, the psychologist who was the person who evaluated everybody said, "Kevin, it's very clear that you look at the world with rose-tinted glasses." And I continue to do that. I mean, I'm a very optimistic person. I really have embraced technology because I think that it is at the core of what medicine really is all about. When you stop and think about medicine, literally for the last 300, 400, 500 years, medicine has been at the forefront of adopting new technologies, whether it's the stethoscope or ultrasound or radiology or antiseptic capabilities, etc. I mean, all of those were "new technologies" at the time. I think we're facing the same thing now, so I'm actually very optimistic.
Brian:
Thank you so much for speaking with us, Kevin. Really appreciate you taking the time.
Kevin:
My pleasure, Brian.

Beyond The Medical Virtualists: Creating Capability In The Health Care Team

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.

The Occasional Random Thought 1/30/18

Periodic thoughts with only peripheral - but definite - connections to health care...
 
Revisiting Thoughts From Ground Zero - I wanted to share these thoughts before we get too far away from the news cycle of January 13th in Hawaii or, as I have come to think of it - "The News From Ground Zero". First, to give my thoughts context - just know that we were there!! After a long flight across the USA, we elected to push the snooze button for just a few more winks rather than get to our early morning start of a meeting. But, even though the snooze button had been pushed, we were out the door of our hotel room at just after 8:13 AM Hawaii time (NOTE: The observant reader will note that my watch in the following commentary runs about 5 minutes ahead of time. That's because I set my watch there so that I stay on schedule J). As we reached the elevators and pushed the down button to head for breakfast, Suzanne's phone startled us with an air raid siren warning and the alert - "BALLISTIC MISSILE THREAT INBOUND TO HAWAII. SEEK IMMEDIATE SHELTER. THIS IS NOT A DRILL." It was in all capital letters nonetheless which for those who are not frequent Twitter users is like shouting!! "...THIS IS NOT A DRILL" got our attention...
 
So, there we are heading down the elevator shaft to the lobby and I responded with the consummate aplomb of an IT guy and a morning shrug by turning to Suzanne and saying, "Must be hackers!" When the lobby elevator doors opened, there was an evolving swell of anxiety that filled the hallway with shouts of: "Does anyone know what's going on?" "Is it really a drill?" "They said we should go back to our rooms and shelter in place!" - This is simply a sampling of the various thoughts and ideas which were bantered about by all of the lobby goers. It was obvious; however, that panic was beginning to set in. By now it was 8:17 AM when we reached an outdoor shortcut to the main lobby across the driveway. Now there were people not walking fast but running about. They were shouting louder and going in all sorts of directions. We looked at one another in disbelief. One passerby said, "There's no basement in this hotel. Where do we go?" to no one in particular.
 
It was then that we saw the bellman who had accompanied us to our room the prior night and who had proudly told us he had worked at the hotel for 27 years. He must know where to go. And, even if he didn't, he pointed us to a steel-reinforced door with a prominent "Medical Clinic" sign with the Red Cross emblazoned across it. I thought to myself, "What an appropriate place for us." My self-thoughts continued, "I might actually be helpful down here in a couple of minutes". There was a whole group of us who nuzzled together to get inside the door and we walked into a cement laden alley way that was obviously a passage way not only to the clinic but also to the laundry area. As we passed a large room of hotel staff, we noticed that there were 20 some staffers in a prayer circle saying a prayer with some in tears, others in disbelief and most in mere shock at what was going on. It was now about 8:24 AM (NOTE: In times of stress, I'm a perpetual watch watcher J).
 
We settled on to a bench and the young woman sitting next to us was just starting a conversation with someone - family we figured. And, it was. She was having a conversation with her brother who just happened to be in the military and, just happened to be stationed at the base in Honolulu and evidently had "No clue" as to what was going on. She finished and reassured us (sort of) that the military had not been notified of any incoming missile from North Korea. Well - this was a moment of truth!! I thought to myself, "If the military doesn't know about it, it must not be real." I then turned to Suzanne for the second time that morning and simply said, "Hackers". We sat there on the bench for some time and as the young woman moved, we moved with her just in case she got any further updates. At about 8:44 AM the same bellman came into the hallway and said, "There is no missile. You can all go back outside." With looks of mutual self-assurance from the gathered crowd we stood up, walked down the hall, and up the stairs into the wonderful ambiance of Hawaii.
 
Heart rates slowed. Everyone took a deep breath. The smells of plumeria blossoms floated through the air. Tranquility seemed to descend over the chaos that only moments before had prevailed throughout much of Hawaii. As we walked over to the breakfast site of our meeting - where breakfast had been promptly closed down by the hotel staff at the first sign of an incoming missile - we learned of many different reactions. By now, it was 8:50 AM (on my watch) and the alarms had started once again but this time with an "all clear" message.
 
There are lots and lots of other stories which I could share from among the Ground Zero attendees. Some were numbing and, even enthralling. There was the young woman who sat on a chair in the lobby sobbing in some sort of PTSD type trance. There was the guy coming back from the beach that had decided to "Go see it all because if you're going to go you might was well see it." There was the multitude of heads shaking back and forth in disbelief. There were hugs and cheers from others with shouts of, "Oh, what a relief." And, there were even more nerdy compadres like me muttering under their breadth, "Hackers, I knew it!" (Actually, a far greater risk that many of the other scenarios).
 
There was also the quiet recognition by a number of us that if the event had happened two years ago - we all (yes, pretty much "all") would have assumed an error - that there was no way a missile strike would be on its way to Hawaii. But, this was the era where the clashing egos of "Rocket Man" and "Orange Man" made the possibility all too real. Such a point in time makes one realize that leadership at all levels of our government is crucial. Leadership extends all the way from the on-call guy in Hawaii who pushed the wrong button to the very top of our nation's government where some leader might push the wrong button. We came home from Hawaii a bit more tired than usual not because of the missile strike but because we tried to cram too many meetings into too short of a time period. And, more importantly, we came home realizing we have a very important goal before us as a people and as a nation over the next several years - which is to re-establish our leadership credibility as a people and as a nation. To realize that objective, we will all need to move from Ground Zero to Action Ground. That will take people voting. It will take energy. It will take fortitude. Go for it...
 
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