S.F. startup lets doc­tors see pa­tients via we­b­cam

San Francisco Chronicle (Sunday) - - FRONT PAGE - By Cather­ine Ho

It’s been about two years since Dr. Ian Tong has seen a pa­tient — in per­son, that is.

But Tong treats pa­tients all the time through a se­cure video-chat­ting ap­pli­ca­tion on his lap­top, from the San Fran­cisco head­quar­ters of Doc­tor On De­mand, the telemedicine com­pany he helps lead as chief med­i­cal of­fi­cer.

The same goes for the roughly 150 physi­cians em­ployed by Doc­tor On De­mand who pri­mar­ily work from home from all over the United States.

The ex­pan­sion of telemedicine — the re­mote de­liv­ery of health care ser­vices through tech­nol­ogy — has spawned a growing co­hort of doc­tors like Tong who spend the vast ma­jor­ity of their time prac­tic­ing medicine through screens, some­times guid­ing pa­tients through self-ex­ams.

Tong, a Univer­sity of Chicago-

trained in­ternist, re­cently in­structed a pa­tient to do a brief ab­dom­i­nal exam on her tod­dler son who was ex­pe­ri­enc­ing bloody stools. As she did so, Tong scanned the boy’s face for dis­com­fort and pep­pered his mother with ques­tions: Has he eaten any­thing red, like beets? Is the blood dark or bright red?

The call lasted 12 min­utes — a bit longer than the nine min­utes Tong says is the av­er­age ap­point­ment time for Doc­tor On De­mand. Soon af­ter, he headed into a meet­ing with the com­pany’s prod­uct team on how to im­prove the app for pa­tients.

Telemedicine is mak­ing ur­gent care faster and more ac­ces­si­ble for many pa­tients but, as Doc­tor On De­mand shows, it’s also chang­ing the way doc­tors work. Gone are the in­stru­ments of the fa­mil­iar exam room, like ther­mome­ters and blood pres­sure cuffs — and the daily com­mute.

“I’d never have imag­ined this is a job I’d be able to do from home,” said Dr. Heather Hawthorne, a fam­ily doc­tor who works for the com­pany from Over­land Park, a sub­urb near Kansas City, Kan. “It def­i­nitely did take some get­ting used to, (like) not be­ing able to put a stetho­scope to their chest to see if it’s bron­chi­tis and not pneu­mo­nia.”

On a re­cent Novem­ber af­ter­noon, while Hawthorne’s 15-month-old son napped nearby, she picked up an im­promptu two-hour shift be­cause there was an un­usu­ally high vol­ume of pa­tient calls com­ing in. Later, when her hus­band came home from work, she worked her usual fourhour shift.

“That flex­i­bil­ity just isn’t there in a tra­di­tional brick-and-mor­tar prac­tice,” said Hawthorne, who did her res­i­dency in Phoenix and prac­ticed for sev­eral years at a hos­pi­tal group in Scotts­dale, Ariz.

This new work­place setup, Hawthorne says, is free­ing but can be iso­lat­ing.

“If you talk to physi­cians in other set­tings, a big part of tak­ing care of pa­tients is (talk­ing to) your col­league like, ‘Hey, I don’t know what this rash is,’ and you’ll ask the doc­tor in the next exam room. It’s kind of iso­lated here. I don’t have that.”

Doc­tor On De­mand, founded in 2014 with fund­ing from Google Ven­tures, Gold­man Sachs and An­dreessen Horowitz, is not the first com­pany to ex­per­i­ment with em­ploy­ing re­mote doc­tors. Other firms based in Florida, Bos­ton and New York have been around longer, and tra­di­tional health care providers have long of­fered pa­tients 24/7 ad­vice lines staffed by nurses.

But Doc­tor On De­mand’s in­roads into the health care sys­tem — its med­i­cal vis­its are cov­ered by ma­jor com­mer­cial in­sur­ance plans like Unit­edHealth Group and Hu­mana, and it con­tracts with a growing num­ber of large self-in­sured em­ploy­ers that pay for some or all of the ser­vices for their work­ers — of­fers a glimpse into a lo­cal com­pany that is rid­ing the telemedicine boom. The firm, which is pri­vately held, hit 1 mil­lion pa­tient vis­its in May, lead­ers said, and is on track to hit 2 mil­lion next year.

“Over the last decade we’ve seen sig­nif­i­cant growth in telemedicine, and in the last five years we’ve seen sig­nif­i­cant growth in con­sumer­gen­er­ated telemedicine where the pa­tient is at home or on va­ca­tion,” said Dr. Steven Wal­dren of the Amer­i­can Academy of Fam­ily Physi­cians, a med­i­cal so­ci­ety that rep­re­sents about 130,000 fam­ily doc­tors. Most doc­tors who work for telemedicine firms are fam­ily, pri­mary care or emer­gency care physi­cians.

In 2014, about 15 per­cent of the group’s mem­bers re­ported prac­tic­ing telemedicine in some fash­ion, Wal­dren said. By 2017, that had jumped to 20 per­cent.

Tong, the Doc­tor On De­mand ex­ec­u­tive, says the more pre­dictable and man­age­able hours help with physi­cian burnout, a well-doc­u­mented prob­lem within the med­i­cal field. The com­pany’s physi­cian re­ten­tion rate, he says, has been over 90 per­cent for each of the last three years.

“In the ER, I worked day­time, evenings, nights, week­ends,” said Dr. Tony Yuan, Doc­tor On De­mand’s med­i­cal di­rec­tor who was an emer­gency medicine physi­cian for 20 years, most of it at San Jose Re­gional Med­i­cal Cen­ter. “It was su­per-busy with lots of trauma. The toll of the sched­ule, the stress of work, it made me pretty un­happy about con­tin­u­ing to prac­tice medicine. When this op­por­tu­nity came up, I im­me­di­ately jumped on it.”

Yuan splits his week be­tween his Union City home and Doc­tor On De­mand’s San Fran­cisco head­quar­ters. On days he doesn’t have to com­mute, he saves about two hours.

Some of the clin­i­cal lim­i­ta­tions to vir­tual vis­its are ob­vi­ous: Doc­tors can’t do phys­i­cal ex­ams, take X-rays, ad­min­is­ter in­jec­tions, treat wounds or do a host of other things. They can, though, pre­scribe med­i­ca­tions and or­der lab tests. But it’s hard to build the type of prac­tice they could in a more tra­di­tional set­ting be­cause many telemedicine pa­tients call in with a one-off prob­lem, like a cough or uri­nary tract in­fec­tion, and ask to see the first avail­able doc­tor, who usu­ally has never treated them be­fore.

The emerg­ing model isn’t to­tally free from the ways of tra­di­tional med­i­cal prac­tices. Physi­cians at Doc­tor On De­mand, for ex­am­ple, get paid de­pend­ing on how many pa­tients they see — sim­i­lar to the way it works for of­fice vis­its. They work in shifts, usu­ally for eight hours at a time, and ro­tate for hol­i­day, week­end and night shifts. Doc­tors have to be li­censed in the state where the pa­tient lives.

“With the ad­vent of tech­nol­ogy and how we’ve de­vel­oped per­sonal de­vices, this will be the fu­ture of medicine,” said Yuan, the med­i­cal di­rec­tor.

But bar­ri­ers re­main. States have dif­fer­ent rules for what they will al­low in­sur­ance com­pa­nies and gov­ern­ment in­sur­ance pro­grams like Med­i­caid to cover when it comes to vir­tual pa­tient vis­its. And pay­ing for the ser­vices out of pocket — Doc­tor of De­mand charges $75 for a med­i­cal visit with­out in­sur­ance — is still out of reach for some of the poor­est and need­i­est pop­u­la­tions. In Cal­i­for­nia, Medi-Cal cov­ers lim­ited vis­its done by video and al­lows pri­vate in­sur­ers to cover tele­health ser­vices, though the de­tails are left up to health plans.

“It’s def­i­nitely ac­cel­er­ated in the last cou­ple years, but there’s still some catch­ing up to do,” Wal­dren said. “Hope­fully, we’ll see the (in­sur­ance) plans pay­ing for this and not out of pa­tients’ pock­ets.”

“It def­i­nitely did take some get­ting used to, (like) not be­ing able to put a stetho­scope to their chest to see if it’s bron­chi­tis and not pneu­mo­nia.”

Dr. Heather Hawthorne of Doc­tor On De­mand

Pho­tos by Con­stanza He­via H. / Spe­cial to The Chron­i­cle

Above: Dr. Ian Tong, chief med­i­cal of­fi­cer at Doc­tor On De­mand, guides a pa­tient through self-ex­ams. Left: A smart­phone app is used to con­nect with Doc­tor On De­mand.

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