Morning Walk #49
What is async communication in healthcare and how do we make it an industry standart
Hi. I’m Stepa Mitaki. I’m a product person and an entrepreneur. I’ve been working in 🏙 govtech for eight years and currently work at a UK-based 🏦 fintech startup Silverbird while building a new company in 👩🏼⚕️ healthtech on the side.
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⚕️What is async communication in healthcare and how do we make it an industry standart
What is async communication?
When it comes to tech startups, the concept of async communication is not new. It is still far from mainstream, but at least a lot of people working in tech are familiar with the idea. Many believe async communication is the next big frontier in the inevitable evolution of the ways we are working after switching to remote and hybrid work thanks to Covid.
Async is short for asynchronous and in this case it means being able to work without having to wait for someone else to answer.
With async you decide when you work, you're autonomous and the only thing that matters is if you get your work done. There's no manager looking over your shoulder, and you don't have to be on-call. You get a lot of responsibility and because of that you make sure you actually do great work. Because if you don't, you lose your job. But evaluating your performance stops being about showing up, it starts being about the quality of your work.
The most common traits of async work are a far lesser number of meetings (which mostly happen synchronously) and heavy reliance on messaging apps and project management documentation tools. Synchronous is your daily standup call with the team, and async is doing that standup by writing a well-structured message on Slack. Synchronous is spending an hour over a video call to make a decision, and async is everyone contributing to that decision at their own time over Almanac.
This blog post from Twist (which claims itself as an ‘async messaging app that won’t distract you all day’) covers in great length all the differences and pros and cons of each approach.
There are quite a few innovative companies out there advocating for async work, and you can learn much about their experience of working async and overcoming its barriers. To name a few: Twist, Gumroad, GitLab, Friday, Basecamp, Levels, and many more. Here is an excellent video from Levels on how they approach team dynamics and stay connected in a remote async culture.
Can we apply async communication to healthcare?
Not just that we can, I firmly believe we should and we will, eventually. Texting is the future of healthcare. Two weeks ago, I explained that telehealth will dramatically transform the way we receive healthcare, and I believe that the first step on this journey is switching primarily to text-based care. Yeah, there are some caveats but bear with me here.
Four years ago, Jay Parkinson, MD, who has practically invented virtual primary care and is often dubbed “The Doctor of the Future,” published an essay titled “Why the doctor-patient relationship should move primarily online,” which explains the advantages of asynchronous communication and problem-solving from the perspective of the patient. Here are just a couple of points from there to give you a general sense of it:
More freedom (no need to make an appointment, just write whenever you want, wherever you are).
More breathing room to respond thoughtfully (in a real-time conversation you might feel pressured and forget something).
A history log of the conversation (you can re-read if you forgot something your doctor said, and the research says that people forget 85% of what their doctor says in an exam room).
Easily share photos.
Receive inline links to complicated concepts or explainers (your doctor can easily link a document or research to give you the full picture if you want to).
Better quality of care (the doctor isn’t pressured to make a decision within a 15-minute appointment on his own, he can take time for a thoughtful response, invite a colleague to get their opinion, and conduct research on up-to-date, evidence-based treatment strategies.
There are numerous advantages from a doctor's perspective as well, according to Parkinson. And, most importantly, text-based is absolutely not the same as video-based care.
None of these efficiencies mentioned above are found in video visits. There are the same scheduling and logistical problems and the same oral conversations and the need to document them that you find in exam room visits. Of course, video visits introduce a technological challenge that doesn’t exist when you can just pick up a phone. And video visits are an unwanted behavior. TelaDoc has stated that out of the meager 1.1 million visits they do per year (mind you, this is the same volume that all the urgent care centers in America do in 3 days of visits), users choose phone over video 90% of the time. The only value gained with video visits are to the patient as they skip traveling to the exam room.
This concept strikes a chord in me when I think about my own experiences as a patient. I hate calling people. I'm nervous in an exam room, feeling I might forget to tell the doctor something important. Frequently I rehearse before going to a new doctor (yes, really!).
Last year I had access to my personal concierge doctor for a couple of months, whom I was able to text anytime, and she'd respond to me within some reasonable time. To me, the best part was being able to message her with any medical question I had and keeping this relationship going with occasional text check-ins.
How can we get there?
Texting your doctor. It seems so obvious, yet it’s just not there yet. To get there, there are many challenges we need to overcome in terms of culture, payment models, healthcare delivery workflows, and tools.
Async communication feels uncomfortable at the beginning. If someone who used to work in a synchronous environment joins a company with an async-first culture, they would require some time to get used to it. It just feels uncomfortable writing down a structured memo instead of setting up a Zoom call.
The same applies to async communication with your doctor. We are not used to that. Many feel more secure and reassuring having a face-to-face conversation, even over a video call. Texting takes more effort than explaining your issue in a real-time call, and because of that, we lose all of the advantages of async communication. We surely can ease the texting experience by leveraging voice messaging (with a transcription for the receiving side, obviously), but there is more to it.
Using a hybrid model seems like a good solution, but we should be cautious. Jay Parkinson, MD, points out that mixing both approaches is not a good idea.
Most important part – mixing synchronous and asynchronous care delivery processes does not work. […] If a traditional office visit synchronous doctor wants to enable asynchronous processes in their practice, this will likely fail. When doctors are busy with office visits and patients can also email them, emails are likely relegated to the end of the day or the weekend. And if patients can email or text their doctor, this is an interruption to the patient in the exam room and these communications are competing with their attention to the patient and their EMR. The doctor will likely answer these communications “when they can” which is often the end of the day or between patients when the doctor gets some down time, further contributing to traditional bottlenecks.
If your healthcare practice is set up for an FFS (fee-for-service) model where you charge for each visit, how do you charge for texting the doctor? There are a couple of options, each with its pros and cons.
Charge for each question
Straightforward for a doctor but a nightmare for a patient. People immediately reduce the frequency, leading to episodic (usually emergency) care.
Charge for each episode of care with free-of-charge texts in between.
Some draw lines. Got a fly and want a prescription? We’ll charge you. Have a quick 5-minute question? That’s on us, don’t worry. This approach is the most common I see these days but somewhat vague for both sides, leading to patients using this very carefully.
You pay 10 bucks for your Netflix each month, and you could pay another 20 to have unlimited texting with your doctor. This seems like a win-win, but the problem occurs when the patient doesn’t need care for a few months and starts feeling like he doesn’t receive enough value. Some practices try to bring more value into a subscription by introducing other offerings, but I haven’t seen anyone truly solving this at scale.
How do you set up a schedule and organize your workday when you need to spend a lot of it texting with patients? Everything in the healthcare industry, from doctor's uniforms to their offices and schedules, revolves around seeing patients face to face daily.
Jay Parkinson, MD, has a great take on this one as well, arguing that health conditions should be viewed as projects to be managed over time by a collaborative team armed with today's project management tools.
This workflow redesign requires a lot of work (and there lies a lot of opportunity for many startups), but I believe it can be solved relatively easily. Another downside of switching to async communication 95% of the time is that doctors will most likely spend most of their time being glued to screens instead of having face-to-face conversations for a change. Can this affect the quality of care? I don't know. But aren't they already glued to their screens with all the documentation they must fill in all day long?
People of many professions have a default app for work communication (Slack or Teams). They have a separate one for private communications (WhatsApp, iMessage, Telegram). Shouldn't we have the same for healthcare-related communications as well? I'm sure both patients and doctors will benefit from it. There are some attempts at this on the market already (e.g., Spruce), but it's just getting started, and there is so much room for improvement.
We will get there
When I started tinkering with the idea of async communication for healthcare, I couldn't get rid of the impostor syndrome. Does anyone really need this apart from me? Will this actually lead to better quality care? Is this more convenient than a video call?
And there are some pioneers in this field that prove this has enormous potential. 98point6, the first text-based virtual clinic, has served more than 3 million customers since 2015 and raised more than $250 million. And Summer Health closed its seed round of $7.5m this July to provide text-based care for child health, offering access to expert, board-certified pediatricians in 15 minutes. Not to mention many virtual clinics that invest more and more into text-based care.
Recommendations of the week
📋 How Big Tech Runs Tech Projects and the Curious Absence of Scrum (read)
Fascinating deep dive into companies of different sizes running their engineering delivery. What surprised me the most was the absence of dedicated project managers and the lack of a “central” methodology in bigger companies (starting from Series A up to Big Tech & Public Tech companies). It’s quite different from what I’m used to seeing in scale-ups.
For team-level projects, not having a dedicated project manager ends up simplifying processes, and strengthening personal relationships. Engineering project leads will add as little process as they can, as this is in their interest. When collaborating with other teams – also without project managers – they will also build relationships for other engineers leading projects, or owning products. This kind of engineer-to-engineer communication is more efficient than if it went through multiple project managers as well.
⏰ Time poverty lowers life satisfaction & well-being at home and creativity & performance at work (research paper)
Turns out that ‘time poverty’ is a thing. And since we are less sensitive to losses of time than money, we don’t notice, but it matters a lot to individuals, organizations, and even nations.
😌 Ladies and gentlemen, the weekend (twitter account)
My new favorite twitter account lately. It tweets the same 4-second clip of Daniel Craig every Friday evening reminding me that the weekend is here.
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That’s it for today. Thanks for reading. Until next week 👋🏻
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