The tools of modern healthcare are increasingly, progressively rooted in a variety of digital technologies — those that power sensors, computers, communication strategies, sophisticated algorithms for analysis, prediction, prevention, decision support, and so on. Many of these tools have already dramatically transformed care delivery in a number of settings (and even created new medical settings).
But even more than the tech itself, the innovations rising from the use of this technology are helping healthcare move into the future — specifically, from its hyper-variable, uber-expensive, frustratingly confusing, geographically maldistributed, and error-prone present, to a democratized, decentralized, smart and learning-oriented future.
Take, for example, Reflexion Health, the company that I lead — a company that uses digital technologies (animated avatars, 3D cameras, signal processing algorithms, etc.) to constructively transform physical medicine and rehabilitation.
VERA™ — a.k.a., our computer-synthesized Virtual Exercise Rehabilitation Assistant — is an engaging avatar that informs and coaches patients throughout their rehabilitation, whether it takes place in the hospital, in the clinic, or at home. So promising is this platform that after a review of information from a a 2018 study published in the Journal of Knee Surgery, Fortune Magazine carried a story entitled: “This Virtual Physical Therapy Is Better and Cheaper Than the Old-Fashioned Kind, Study Says.”
This is obviously encouraging, supporting decades of similar studies pointing to digital healthcare delivery as a new era of cost savings and quality of care. As a case study of this promise of digital healthcare like VERA to transform healthcare delivery for the better, let’s consider 5 key ways this innovative platform is already transforming the possibilities of physical medicine and rehabilitation.
#1: Move data, not people: Defeating the tyranny of geography in healthcare
The Flexner report on American Medicine is best remembered for helping transform physician education in the United States. In his storied report, issued back in 1910, Abraham Flexner called out many shortcomings of U.S. healthcare education and delivery, and championed the academic model of physician training and education typified at the time by Johns Hopkins University.
One shortcoming highlighted in the report, but left unaddressed by the resultant transformation, has been the maldistribution of clinicians. With practitioners increasingly concentrated in larger cities, many smaller cities and rural areas are being left underserved. Today, the Health Resources and Services Administration (HRSA) recognizes more than 7,000 American communities as being “Designated Health Professional Shortage Areas.”
“The rural district is therefore entitled to the best trained physician that can be induced to go there,” predicted the Flexner Report more than a century ago. “But, we are told, the well trained man will not go; he will not pay for a high-grade medical education and then content himself with a modest return on his investment.”
We have yet to implement effective incentives that would appropriately distribute clinicians in a geographic-need basis. Rather, the progressive sub-specialization of healthcare since the time of that report has only amplified the geographic maldistribution of needed services, yielding the conventional wisdom that “all healthcare is local.”
Unfortunately, this directly implies that the fate of in-need patients is largely determined by the quality and distribution of the services that happen to be available within their local region. When it comes to healthcare, patients suffer the tyranny of geography.
This is exemplified in physical therapy. Whether suffering from a painful or disabling injury or recovering from a recent surgical procedure, PT patients must often repeatedly travel from home to the therapist’s office, clinic, or hospital to receive effective supervision of their rehabilitation program (along with the associated pain, stress, logistical challenges, and costs that go with that travel).
In some settings, it’s possible to alleviate this issue with home visits performed by physical therapists, but the economics render this approach unsustainable. Other, less personalized models of care often leave patients with only a set of printed instructions, with no real encouragement or coaching, and the understandable poor adherence that results.
Enabling professionally-guided therapy at home can help alleviate this issue. VERA uses 3D imaging to digitally measure, monitor and record patients’ rehabilitation sessions, and then uses complex algorithms to analyze their movements and provide valuable insights. Using the VERA platform, patients have an on-demand aid in their physical therapy, and clinicians have the opportunity for frequent assessment and timely course correction.
Technology also affords the opportunity to provide real-time clinical guidance, education and coaching for recovering patients, no matter where they’re located. Automatic and detailed performance measurements along with objective documentation of progression can be gathered in the safety and comfort of a patient’s home. Finally, digital technologies can answer the call to provide expert care to the most remote patients.
#2: Empower expertise: Allowing clinicians to function at the top their license
Worsening the impact of the maldistribution of clinical expertise is the relative shortage of a wide variety of doctors and healthcare professionals, including physical therapists — a shortage that’s projected to grow more severe in the years to come due to our nation’s aging demographic.
With actual shortages of physicians, nurses, and clinicians compounding the adverse consequences of maldistribution, it becomes even more imperative to assure that busy clinicians are always making the best use of their time, working in those settings and with those patients most in need of their specific skills.
To achieve this, processes of care should be routinely informed by expert judgment, then automated where possible. These processes should be objectively tracked, along with exception-based reporting of those circumstances that fall outside of normal trajectories.
In the case of virtual physical therapy, an automated monitoring process that frequently and carefully inspects the patient’s recovery trajectory for any subtle deviation from their expected course can help ensure that true clinical expertise is focused and brought more quickly to bear when needed for early intervention.
When technology enables care to be given without the requirement that clinicians and patients be in the same place at the same time, optimization over a broad population with varying needs becomes much more manageable.
#3. Measure to manage: Objectively & quantitatively capturing the subjective
There is a widely held management dictum attributed to management guru Peter Drucker that holds that: “If you can't measure it, you can't manage it.” Physical therapy is no exception to this rule.
Continuous, in-person clinical supervision of individual patients with reproducible objective measurements as they progress through the various stages of recovery is ideal, yet logical implications and system costs render this impossible. The compromise currently being made — infrequent visits between patient and clinician — result in only brief snippets of time for assessment and coaching. For the bulk of the time, patients are left on their own, encouraged to follow a set of instructions regarding their self-directed rehabilitation efforts, with little incentive to engage and no way to offer observable progress.
Without sufficiently frequent and sufficiently detailed, objective metrics of the recovery process,
it becomes nearly impossible to determine which of many different therapeutic approaches yields preferential results, or in the event of a problematic recovery, what precisely went awry. Lost is the opportunity for timely identification of issues, appropriate intervention, and best-practice identification. Rather, individual tastes, experiences and local traditions play larger roles in determining treatment plans, and hoped-for adherence and watchful waiting are substituted for a well-managed recovery process. Observation bias, confirmation bias, and the inertia of the familiar tend to reinforce the status quo.
What has resulted is a patchwork of highly variable approaches, with limited insight into which aspects of which plans may be most useful, effective or desirable. Much of the site-to-site and clinician-to-clinician variability may then have uncertain value, but in the absence of objective and comparable metrics, there is no effective arbiter, no way to declare a “best” approach, either in general for a population, or in the specific case of a specific patient presentation.
A digital healthcare platform like VERA can help. By first making assessment of the patient’s functional limitations during the pre-hab interval, retaining documentation of the procedural details, making automatic and objective measures of every attempted exercise in recovery, objectively and quantitatively tracking adherence to prescribed therapies, and performing frequent functional assessments and eliciting and documenting patient reported outcomes, we can begin to determine what elements contribute to the most rapid and effective trajectory for return of function.
#4: Learn from every encounter: Minimizing non-value–added variability
A smart, forward-thinking, learning-oriented healthcare system is designed to function in a way that gets better with every experience. Every patient experience is measured and documented in a way that allows for some incremental understanding of what is working, what isn’t, what opportunities exist for improvement, and how such improvement might be achieved.
Without careful, repeated, and objective measurement of the process of healthcare linked to objective outcome metrics, the opportunity for such learning and improving is lost. Innovations in the digital healthcare arena that enable such careful and objective measurements linked to outcomes are then the building blocks for a smart, learning healthcare system.
Take VERA for example. By melding gaming-level animation with 3D imaging for careful capture of patient motion, and by comparing prescribed physical therapy regimens (and adherence to them) to ultimate outcomes achieved by a broad array of patients from a wide range of clinical settings, it becomes at least theoretically possible to exploit the “experiment of nature” currently taking place in healthcare — that is, to identify those elements of care (frequency, type, duration, of exercise; type of implant; surgical approach; etc.) that meaningfully impact the overall patient experience and outcome.
Then, by systematically altering such elements in carefully controlled studies — always with careful, repeated, and objective measurement — the path becomes clear for iteratively identifying what truly works to improve outcomes. But none of this happens without first putting in place careful, frequent, and objective measurement, such as enabled by platforms like VERA.
#5: Every opportunity to engage: Making the right thing the easy thing to do
Even when the hard work is done and the results are in, and we have conclusive evidence of the optimal strategy for obtaining a desired clinical result, there is still often much that separates what we can achieve to what we actually do achieve.
This “can-do gap” is enormously frustrating for health services researchers, as well as for the healthcare community in general, as it speaks to our inability to turn hard-won understanding into otherwise well-deserved improvements.
In the case with physical medicine and rehabilitation, we’re still far from knowing what is the absolute best strategy for each and every patient. But even in those instances when we have great confidence about the role of specific therapeutic exercises in well-defined patient groups, we still know that patient adherence to our recommendations is most often below 50%, more typically in the range of 15-40%.
It’s obvious, but it’s no less true that patients need help adhering to prescribed therapy. They receive no benefit from pills they don’t take, therapy they don’t perform, and changes they don’t make. Digital healthcare technologies can help drive engagement. As researchers concluded in the Journal of Knee Surgery study, interactive virtual rehab platforms like VERA are “geared to improve adherence and overall patient satisfaction."
In the case of Reflexion’s VERA platform, the presence of the technology in the home is a potent reminder of the need for patients to perform their prescribed therapy. The animated avatar provides engaging and personalized instruction. The input each patient receives about their progress creates a reward structure that keeps patients engaged and motivated. Together, these separate elements are a potent recipe for engagement and adherence.
The integrated telemedicine application makes VERA a center for communication between the patient and the clinician, reinforcing the centricity of the platform in their care and encouraging them to complete the prescribed therapy. The camera that records every therapy session reinforces the sense that the treating clinicians are “looking in” on them.
While it is difficult in practice to tease out exactly what influences drive the overall result in each case, it is clear that in use today, the VERA system drives compliance to prescribed therapy (using the rigorous metric of percent exercises prescribed that are actually performed correctly) to more than 75%. This compares to the subjective reporting of only 15 to 40% when patients are asked by their clinician about their adherence to paper-based instruction.
In use today, this enhanced compliance is associated with patient recovery times of 29 to 30 days (average of 150 patient cohort) compared with historical controls of 55 to 65 days. These observations are consistent with conventional wisdom that better adherence to prescribed therapy yields a faster recovery.
Digital healthcare: Leading the way into the patient-centric future
Digital healthcare solutions are inherently patient-centered. Internet-based accessibility means that patients can be engaged wherever they are, with technology that can bring the guidance of expert clinicians directly to them. And VERA is just one example of digital healthcare solutions that are saving time, travel, worry, wait, and costs for all involved.
Patients see VERA as a way to skip the burdensome trips back and forth to their clinicians’ offices, saving gas, parking, and the cost of co-pays in the process. Clinicians benefit, too, from lower rates of missed appointments, and from more real-time information available on their most challenging patients at a moment’s notice. By pulling out so many of the frictional costs related to logistics and travel, the end solution is convenient, cost-effective, and delightful to patients and practitioners.
Digital healthcare isn’t a new, alien form of healthcare. Instead, it’s a tech-enabled transformation of delivery that can make healthcare simpler, easier, more patient-centered, data-driven, and value-based.
It represents the creative use of established and emerging tools to fulfill key elements of an optimal healthcare delivery system — one that meets patients where they are, defeats the tyranny of geography, brings expert care to the most remote settings, and in doing so provides easy access to excellent outcomes at lower cost.
Dr. Joseph (Joe) Smith is President & CEO of Digital Health Corp and Reflexion Health.