November 2, 2016

Scaling Up: Jason Hwang and Asynchronous Telemedicine

Robert Graboyes

Senior Research Fellow
Summary

Such scaling would do for segments of medicine what mechanization did for farming — allow more and better care while radically lowering costs. We could reduce health care spending and workforce, or we could shift redundant resources toward high-valued healthcare uses.

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Healthcare has barely begun to scale — to get more care from fewer doctors, nurses and hospitals. But we can glimpse the scalable future in asynchronous telemedicine, where patients and doctors interact remotely, but not simultaneously (analogous to email). Dr. Jason Hwang is a pioneer in this area.

Medical professionals often ask me two questions: “How can we lower healthcare costs?” and “How can we medical professionals shore up our bottom lines?” My response is, “You realize ‘healthcare costs’ are you, right?”

If “lower healthcare costs” means lower aggregate spending, then as Megan McArdle recently wrote, “Americans must use less care,” and healthcare professionals must be “less numerous and less well paid.”

To understand scaling, think of agriculture. In the mid-19th century, 70 percent of American laborers worked in farming. Today, it’s fewer than 3 percent. Farming declined from around 40 percent of the economy to under 1 percent. Yet, food prices plummeted vis-a-vis other goods. Malnutrition, once commonplace, largely vanished.

Not all healthcare can massively scale. Some care will always require one doctor and one patient together for 15 minutes. You can’t shrink those visits to two seconds or have the doctor see 500 patients simultaneously.

Synchronous telemedicine — patient and doctor talking via video — offers some efficiencies. California tele-docs can help bear the load of patients suffering through an epidemic in New England. But this still means one doctor serving one patient throughout the examination.

Certain services, however, are scalable. Traditionally, routine prescriptions like birth-control pills required one doctor to focus on one patient — gathering medical history, assessing risks and benefits of treatment options, writing the prescription, educating the patient, planning follow-up care, documenting the encounter, billing. Asynchronous telemed automates much of the process, which facilitates scaling.

Jason Hwang is a California physician and MBA. Clayton Christensen, Jerome Grossman, and he co-authored the path-breaking medical innovation book “The Innovator’s Prescription: A Disruptive Solution for Health Care.” He has been a medical school instructor, practicing internist, think-tank director and entrepreneur. Until recently, he was chief medical officer of Lemonaid Health, an asynchronous telemed company he co-founded.

Using Lemonaid’s secure website, patients can request pills for birth control, acid reflux, acne, erectile dysfunction, flu, hair loss, sinus infection and urinary tract infection. During office hours, turnaround time is two hours, but the portal is open 24 hours a day. The cost is $15.

Lemonaid automates many steps that previously bogged down physicians. It automatically educates patients about services provided, treatments available and who should or shouldn’t use the service. It walks patients through standardized questions that mirror what an in-person doctor would (or should) ask. With standardized output, one physician at a Lemonaid dashboard can safely review many patients’ responses at a glance. A few mouse clicks will send the prescriptions to patients’ respective pharmacies. The system coaches each patient on follow-up care and handles billing.

Jason says his co-founders’ British company, Lloyds Online Doctor, has demonstrated one doctor can safely handle a flow of 1,000 cases per hour. He speculates that, eventually, a few dozen doctors could safely, effectively handle much of the day-to-day chronic disease management and basic care needs of the entire United States.

Such scaling would do for segments of medicine what mechanization did for farming — allow more and better care while radically lowering costs. We could reduce health care spending and workforce, or we could shift redundant resources toward high-valued healthcare uses.

Current regulations, designed for a brick-and-mortar world, slow the spread of asynchronous telemedicine. Lemonaid physicians need separate medical licenses for all states the company serves. Some states require patients to have in-person or synchronous telemed visits before using a service like Lemonaid. Today’s patchwork electronic health records make it difficult to meld in-person and telemedicine visits into integrated care. Some tele-doctors want regulations requiring equal payment for in-person and telemedicine visits — defeating the purpose of low-cost providers like Lemonaid.

“We’re still a long way from having robot doctors,” Jason said, “but Lemonaid could be described as a precursor to the artificial intelligence that will one day let us manage our health effortlessly, throughout our daily lives, using the devices we carry with us everywhere.”