Can telemedicine save the soul of palliative care? Dr. Michael Fratkin tells us how virtually delivered palliative care lightens the load of dying patients, increases the effectiveness of pressured providers, and elevates the role of ‘healers’ in the healthcare of the future.
TeleMedMag: You transitioned from a traditional hospital-based palliative care model to crowd- funding ResolutionCare, an innovative telemedicine approach to palliative care. What was your impetus to leave the traditional structure?
MICHAEL FRATKIN: The backdrop was eight or nine years of doing palliative care in an under-resourced department where there was always ridiculous demand for the capacity that I had. ere were al- ways three, four, or five requests for consultation for everyone that I could do, and no responsiveness from inside the institution, which was bound to a productivity and revenue generative model of providing re- sources and support. If you’ve got a fee-for- service structure and doctors are the engine of economic energy, a palliative care doctor doesn’t fit well into that structure. The palliative care visit is about two or three times as long as the fee schedule supports. In palliative care, time is our gift to patients. It’s not a spectacular amount of technical support or technical information or procedural skill. It’s sitting down and talking to people. So any palliative care program is subsidized to at least 50 percent of just the doctor’s salary. I just couldn’t squeeze that out of our organization, no matter what. So I was operating in an environment where most of my day was spent triaging to figure out who was the most miserable person I could take care of. And that was distressing and suffocating over time.
As 2014 emerged, I knew that I had to make a change. I was backing into this reluctant idea of working for a bigger organization, one that was better resourced, but a kind of corporate or industrial delivery model. Ultimately, I didn’t want to do that, and I didn’t want to leave the area. I’ve been here in Humboldt county for 18 years now, and I’ve probably taken care of 1,500 people who’ve died. And that’s soul. I run into the friends and family of my patients in the produce section, in the park, and at the farmer’s market. I love walking through a town being a symbol for caring. at gives me a sense of place.
So there I was. I had this dilemma. There’s only one game in town, institutionally— one hospital system, and they weren’t going to pony up.
TelemedMag: So plenty of doctors see the problem. What caused you to actually go outside of the system to create a solution?
FRATKIN: Two things emerged in early 2014. One was the short-lived project by Google, called Google Helpout. It was an online collaboration platform that they played around with which allowed users to share their expertise through live video. A friend who works for Google suggested that I do one for palliative care. So I made a web page. I offered it for free. I put it out there a little bit in social media and I engaged with four or five people, making it clear I wasn’t doing medicine but offering some counseling regarding issues of serious illness.
I used the platform with a few of the patients that I was already caring for. After five or ten encounters, Google cancelled the project, but I had discovered that the relation- ship space that emerges over a reasonably good quality video conferencing platform is powerful, and it just plain works. I was like, Wow, telemedicine. And then in June 2014 I read about Sanjeev Arora and the University of New Mexico’s “Project ECHO” in the New York Times. It inspired me with this idea that if you have a reasonably seam- less platform, you can use video conferencing technology to share scarce expertise and force multiply your impact. And that just matches the palliative care problem enormously. We have huge workforce shortages and exploding demand for services, and a difficulty in terms of a revenue model.
Then I was introduced to the Zoom Platform, which is cloud-based video conferencing, HIPAA compliant, and incredibly intuitive and better than anything I’ve ever used. Zoom is so easy that little old ladies can be coached in ten minutes to engage with ease. At the same time, the consumer technology was maturing. Devices are everywhere. Broadband internet connectivity is everywhere.
Finally, these moves aligned with a larger trend in the industry of sitting people in their homes rather than inside a clinical environment. The trend is now shifting toward community-based care, engagement with the medical home.
TeleMedMag: So the stars aligned for you to leave the hospital setting and build something new in ResolutionCare. Why did you decide to begin with crowd-funding?
FRATKIN: The crowdfunding piece has just been kind of percolating in the back- ground. I’ve supported a number of people in their efforts and have been kind of interested in how that worked. But by the time I encountered video conferencing for the practice of medicine, Project ECHO, the Zoom Platform, and all of the energy around it, I realized that I needed to go out and find some startup money. Crowdfunding just dropped into my consciousness. I found a consultant and pulled the trigger actually almost exactly a year ago.
TeleMedMag: Logistically, telemedicine is great. You can be in more places at once. You can see more people. But palliative care is so personal. Can a video visit really replace the house call? How much of a degradation in quality is there?
FRATKIN: That’s kind of how I thought about it at first. I thought that I’d be giving something up but that maybe I’d be get- ting enough in return to make it valuable. But that’s actually not what has happened. As it turns out, the telemedicine platform and the capacity to connect and engage is entirely superior in certain elements to a face-to-face.
TeleMedMag: Superior to face-to-face?
FRATKIN: Just imagine that you’re a little old lady with metastatic breast cancer. You’ve had 150 visits in the last year of your life for lab work, infusions, doctors’ appointments, X-rays, episodic care in the emergency department, maybe a hospitalization or two for a complication, maybe radiation therapy. Literally 150 visits to some site of care. And then I add myself to that mix, and I symbolize death and dying. To tell that same person: “Listen, we’ll come to you, either in person or virtually. You don’t have to go anywhere. And we think we can help you with your symptoms.” So that little old lady doesn’t have to spend two, three hours getting ready in the morning (because she has this culturally normative behavior to dress up for the doctor). She doesn’t have to get out of her fuzzy slippers. All she has to do is click on a link in an email with a device that either she has or her granddaughter sets up, or we send a community health worker to set up, and click through to the doctor. The patient didn’t have to get dressed. She didn’t have to get into her wheelchair. She didn’t have to get into her car or get her family member to take her. She didn’t have to drive the average of 25 miles around here to get to the clinic. She didn’t have to park and get schlepped into the office. She didn’t have to deal with the waiting room. She didn’t have to deal with the snotty front desk staff and the damn clipboard with all the redundant information. All she had to do is click on a link. So there’s one major advantage; by the time we see each other all of that stuff isn’t in this space. And then I can create the illusion, which is generally not an illusion. I mean, I presence myself before I click on my link; I just drop in and there I am magically in this communicational space, this relational space. It’s like a tunnel that connects me to this person.
TelemedMag: How has your workflow changed since moving to virtual visits?
FRATKIN: I didn’t really understand this at first, but I’m starting to see that there’s a magical efficiency that’s built into a virtual visit. I used to give two hours for an introductory meeting with a new client. With the video visits, I allotted the same two hours, but all of a sudden an hour has gone by and we’re done. When you’re holding a person’s attention inside this kind of magical tunnel, it’s just you and them (plus whoever else might be around), and that quality of attention is an advantage.
TeleMedMag: What are the downsides to virtual palliative care visits?
FRATKIN: What you give up are hugs. You give up eating their cookies on their couch. You give up really strolling around their house freely, looking in their refrigerator, seeing how they store their medicines. But actually, depending on the person and who’s there, we can still accomplish some of this. I ask them to give me a little tour around. I also give up having their dog hump my leg and bark at me. Dogs are a lot happier to look at me on the screen than in the house.
TeleMedMag: How do you extend yourself physically into the community. At-home aides? Nurses?
FRATKIN: Palliative care is by definition an interdisciplinary team. A palliative care specialty trained provider is a part of the team that includes a palliative care nurse, a palliative care social worker, and a palliative care chaplain. In our practice there is a really exciting opportunity for development which we’re calling a “community health worker.” That person is sort of boots-on- the-ground, base-of-the-pyramid, and will rarely use the video conferencing technology. They are the ones most often out and about in the eld, answering questions, identifying problems, looking in the cabinets, and all the rest. And they’re coming from a world of the most talented and able caregivers: private hire caregivers who just have a certain special talent for this work. Our community health worker, Kat, is really in some ways the most profound leader on the team, because she spent ten years working in hospice giving bed baths to people who were dying. You could send her to school and they’d give her letters to put after her name, but that kind of almost tactile understanding of what’s needed is leading the team to respond in creative ways to meet the needs of these people.
TeleMedMag: And that frees you up to do the work you need to do behind the screen, knowing that she’s out there.
FRATKIN: Absolutely. I could send a nurse out there to say: Can you find out how she’s taking her medicine? Can you inventory what’s in the home? And can you do some teaching about the fundamentals of patient-empowered use of medication? The doctors in offices have this sort of magical thinking that they write a prescription and that’s how it’s magically taken. And then they adjust the medication instructions from the list, and we know how terrible people are at taking their medicines. For control of symptoms, it’s not rocket science. We just have to find out how they’re taking it and train them to take them in a sensible way.
TeleMedMag: Everyone is trying to reach the consumer with these different digital health devices and apps and wearables. Beyond the video interface, is ResolutionCare starting to incorporate other digital health devices and wearables so that you can gather
FRATKIN: We have a relationship with a really great little company called TapCloud, which is an mHealth application that we’re going to be loading onto a set of tablets that we provide to our clients. It gives them an opportunity to communicate with us, and it’s a creative, interesting way to track how they’re feeling. It gives them notifications and prompts: Have you had a bowel movement today? Have you done [this or that]? Those data get uploaded to a dashboard, then we play around with what we discern are potential high-quality applications that will give us that kind of information. More importantly, it will hopefully engage the patients in an interesting way that fits into their life.
Rather than use a linear pain score, TapCloud has this unique kind of intelligent swarm of words that gives people a chance to identify things of importance. For example, if yesterday they said that their pain was getting worse, today pain will be in a larger font. And when they tap it, it’ll ask them a question that will relate to yesterday: better, worse, or the same? If they’re having trouble with their caregivers, or are about to run out of a medication, or their advance directive hasn’t been formed, that’ll populate as a larger font and a prompt. So this cloud that they tap on each day to give information kind of learns their communication style and tracks certain things in a seamless and organic way.
The more important point is that what we’re doing has almost nothing to do with technology. What we’re doing is human-centered care of human beings, in their homes, with whatever tool is available, just like it’s been for all of human history.
People approaching the end of their life are not having a medical experience. They’re having a human experience. And what matters is being heard, being in control, and understanding what tools there are in the environment so that they can make choices about it. The best part about our technology is that it tends to disappear almost instantly. And then it’s just about people.
TeleMedMag: Often physicians fear that telemedicine will kill the personal nature of the doctor-patient relationship. Some of them might already have difficulty relating to people, and video will just add another layer of distance. How do you retrain these physicians to use this technology effectively?
FRATKIN: I think that we’re doing in palliative care is responding directly to that. What we want to work with are people who already have a certain sensibility about the primary care role—about the importance of trust and relationship. We want to pro- vide them with a handful of skills. Again, palliative care is not rocket science, as much as the academics might want to distinguish themselves as huge experts. It’s just human beings looking at each other like human beings. And from my point of view, that is exactly right.
If we can inspire people to settle down and drop their role, drop their identification, their strict and concrete identification as a doctor who’s driving medical science down the throat of a human being who’s having a human experience, then we can give them a handful of skills. More importantly, we can infuse a certain mindset that our patients are begging for: they are begging to be seen as people.
So the pain points for all the stakeholders are technical and evidence-based, and even academic, and also economic. But the experience of being a sick person in our absurdly complex system responds most importantly to just being connected. They want to know that you give a shit. And if you give a shit, then that’ll come through. And we want to teach doctors that it’s safe to care, and that their relationship is not fraught with fundamental antagonism. One of my catch phrases is, “What we’re doing is restoring the traditions of trusting alliances for healing by using the technology that happens to be available in 2015.” Next year we may nd something better, or we may get rid of TapCloud and put some kinds of constipation monitoring devices on our patients. I don’t know. If it helps to improve their quality of life and their satisfaction with their experience, as well as reduce costs, that’s the holy grail, the triple aim, right?
TeleMedMag: What’s one piece of advice that you would give to a doctor who’s hesitant to use telemedicine because of this fear of a loss of human interaction?
FRATKIN: The technology disappears. And the only way to really discover that, since people are so filled with their assurance that their biases are correct, is to try it. Try it. Think about how doctors must have felt about doing telephone work. And think of all the meaningful work and engagement that doctors do with the telephone to for- ward the well-being of people. Add a whole order of magnitude of greater impact and engagement by visually connecting in real time with people.
TeleMedMag: What if the clinician is truly not good at relating to people and the telemedicine platform is going to really create a barrier? How do you teach a young physician to make a more human connection?
FRATKIN: That’s a good question. It really has to do with just simply showing up as a person. I mean, whether it’s in-person, on the telephone, or over video, check your own shit at the door and show up for these people. I want to be able to inspire people to love their work and to understand its real value to people. But I can’t give them the recipe for being a human being. But it’s being a human being that answers the profound unmet need of other human beings.
TeleMedMag: There are some people who really struggle with empathy out there.
FRATKIN: Yeah, well, they might have gotten into widget making or something else. Not everybody is a healer. For the last 70 years, we actually have not been selecting our physicians and providers as healers. It’s a selection problem. I’m willing to work with anybody to inspire them toward this end, because I know that they’re actually humans. They may not know how to just relax and be that way. But that’s what our future is calling for. Not just in healthcare but in political discourse, in communication, and content creation. Can we actually get real and authentic in the personhood that we assume in life and in society?
TeleMedMag: One of the undercurrents I hear from you is the importance of humility, of having doctors let go of their identity and drop their merit badges a little.
FRATKIN: That’s right. And I think that over the next 20 and 30 years we’ll see that those folks are selected against. I think that the answers to the future character of our healthcare delivery system and well-being systems as a society will not be determined by how bright and clever guys like me and policymakers and payers and stakeholders are—the future of our healthcare system will be determined by empowered people with illness. People and populations are getting involved in moving these recalcitrant institutions from the status quo to something that actually serves their needs and at lightning speed. I’m just a part of that wave, not as a doctor but as an entrepreneur— somebody who’s just looking at the problems and following the currents of change.
TeleMedMag: So what’s next?
FRATKIN: I think we are going to welcome back into the training process in medicine people that have a much deeper connection to what it actually means to step into somebody else’s life and offer service. Whether that’s with cardiac surgery, brain surgery, radiology or whatever; my hope is that the society will change the selection criteria and that we realize that medicine is not fundamentally technical. It’s funda- mentally human.
We’re going to have artificial intelligence that’s way smarter than even the geekiest nephrologist and it won’t be long before the technology does all of that intelligence- based heavy lifting. And what will be left for doctors is to be a guide and to be wise, just the way it always has been, long before medicine was medicine.
TeleMedMag: Now that you’ve been running ResolutionCare for a year, what are the technological pain points that you have running the business? Is there a program, an app, a device that you wish that you had now, that you hope gets developed?
FRATKIN: It has to do with the economics. Value-based payment is the key. If those that pay for healthcare agree that palliative care is an extra layer of support to the care that people are receiving in other practice settings, whether it’s cancer care or cardiology care or chronic disease management; if they say that it’s worth it to have palliative care, then it will be paid for in a way that’s not based on fee-for-service. All those trends are emergent. We’re involved in a pilot program that pays us a set amount per month to deliver on the outcomes that we agree on.
And so they don’t care if we see a patient by telemedicine, carrier pigeon or smoke signals. They don’t care if we see them three times a day or once a month. They don’t care if it’s a social worker or a chaplain. They just pay us per member per month to deliver on quality as defined by the patient: quality of life; satisfaction as defined by the patient; and to deliver on a reasonable return of investment. That economic revolution changes everything in healthcare and palliative care is perfectly positioned to take best advantage of that. Because we deliver on patient-centered goals, as the air that we breathe.
But in terms of the technology, the electronic medical record is the world’s greatest technological albatross for every practice setting that there is. The medical record must be transformed, from my point of view, into an information sphere with the patient inside and inviting all of the other participants to share information. It doesn’t become a documentation and coding structure. And so my only hope going forward is that somehow the electronic medical record can transform and get out of the way and become actually seamless and invisible, like the video conferencing technology.
My only hope for that is the iconic provocateur Jonathan Bush from Athenahealth. He’s the only one who’s in the business who’s willing to make his platform open for APIs. And he is the only one willing to say that electronic medical records suck entirely and their impact on healthcare delivery and the fulfillment and satisfaction and experience of people providing healthcare, it’s driving people to suicide, drug addiction, burnout and all the rest of it. My hope is that the economics that come along with value-based payment and outcomes-driven payment models transform the electronic medical record.