Diagnosing and treating a patient in two minutes flat

Virtual healthcare is having a moment.

More patients are demanding electronic access to care. Physicians are looking for new ways to provide convenience. And most major insurers are now paying for it.

The technology is rapidly evolving, too. High-quality smartphone cameras, faster internet connections and connected medical devices are giving telehealth providers the ability to seamlessly replicate the experience of the in-office primary care visit at a much lower cost.

But while video visits alleviate the barrier to healthcare created by distance, especially for patients in rural areas or simply those with busy schedules, they do little to address the nation’s growing problem with physician burnout. Indeed, by increasing demand for healthcare services, various forms of telehealth could worsen the shortage of primary care physicians in the years ahead, said Dr. Ray Costantini, a physician and founder of Portland, Ore.-based virtual care startup

Telehealth “removes the geographic barrier to care, but it doesn’t solve that underlying supply and demand issue,” said Costantini, who became “a little disenchanted with telehealth” during his time heading up the digital health services group at Renton, Wash.-based Providence Health & Services. “In fact, what I saw and what every delivery system I’ve worked with has seen, is that delivering care via video actually takes more provider time than delivering that same care in person.”

And time is something busy physicians do not have to spare. So in 2014, Costantini created’s SmartExam platform to offer healthcare providers all the benefits of remote care for low-acuity conditions, but with greater efficiency and without the added workload. It promises to cut the provider’s time spent on each virtual visit to just two minutes. To compare, physicians spend about 13-16 minutes with a patient in an in-office primary care setting, according to a 2016 Medscape physician compensation report.

SmartExam works like this: Patients log into the platform and answer a series of questions about their symptoms and health history. They can upload images of a rash or take a guided physical exam. Patients then fill out their pharmacy and billing information. The process takes about 8 to 12 minutes.

Then, SmartExam combines the patient’s responses with information pulled from their medical record to come up with a likely diagnosis. It sends all of the information in a chart-ready note to the physician, who is alerted that a patient is waiting for care. The physician can then select the appropriate diagnosis and treatment plan — or enter a new one — and send a prescription to the patient’s selected pharmacy, if needed. All the information is then folded into the patients’ medical record.

“We’re gathering, organizing, displaying and making actionable all of the information that a provider needs in order to be able to exercise their clinical judgment in the most efficient way possible,” Costantini said. It’s almost as if a hospital’s best resident is able to beam into the patient’s house, conduct a thorough interview, and synthesize it into exactly what a doctor needs to do its job, he added.

The promise of patient convenience without the extra burden has won a growing fan club among hospitals and medical groups who have or are getting ready to deploy the platform. They include Greenville (S.C.) Health System, Rush University Medical Center in Chicago, Adventist Health Medical Group in Portland, among others. Costantini declined to say how many health systems works with, though it is currently available to more than 7 million patients.

That number is sure to grow. The startup, which raised $3.5 million in funding in 2015, was named one of Gartner’s “cool vendors” for health IT in 2016 and became the chosen platform for AVIA’s cohort of eight major health systems evaluating virtual access. AVIA is a national network of health system innovators that itself receives venture capital from health systems.

Adventist Health Medical Group, which operates 34 clinics throughout Portland’s metro area, will make SmartExam available to established patients at several clinics starting in April, and roll it out to all patients by the of the year. It will encourage those with simple, uncomplicated conditions to seek care through the platform, allowing clinics to free up in-person appointments for patients who need them most.

SmartExam is now available to diagnose more than 350 conditions that make up between 30% and 60% of the care delivered in primary care offices, Costantini said. Ear pain, seasonal allergies, urinary tract infections, rashes, coughs and colds are some of the most common conditions treated.

These are low-acuity conditions that “in fact do get managed all the time over the phone, though providers are disinclined to do that because there’s no reimbursement,” said Dr. Ralph Prows, Adventist’s chief medical officer. Reimbursement for SmartExam, which is billed as an e-visit, is in the ballpark of $40 to $65 per visit, Costantini said. It’s a win-win, because providers get paid and patients pay just $20 for treatment, he said.

Starting in April, Rush University Medical Center will deploy SmartExam to all patients who have had a primary care visit in the last two months. “We wanted to give people options that really work for them,” said Dr. Anthony Perry, a physician and vice president of population health and ambulatory care at Rush.

The health systems that have signed on to work with SmartExam see no issues with the quality of care. Some who are still holding back wonder if a questionnaire-based virtual care provider can measure up to an in-person or video visit.

Costantini said works with a team of clinicians to ensure that the platform’s questions and diagnoses adhere to evidence-based clinical guidelines. Moreover, the questionnaires, which can range up to 75 questions, are more thorough than those usually asked in an office visit, he said.

“In an in-person or video setting, you got four or five, maybe six minutes, actually asking questions to the patient,” he said. “We’re able to be much more thorough and we’re able to do it in a way that’s really delightful for patients…They don’t feel like the provider is having to hustle out of the room to see the next patient.”

Costantini is reluctant to characterize SmartExam as a platform for low-acuity care, because he envisions it largely as a care automation technology that can transform healthcare as a whole. The startup is building out modules to diagnose new conditions on an ongoing basis.

Costantini wouldn’t share specifics. But “there are a lot of conditions that are amenable to being able to be more efficient and more thorough and more evidence-based through this kind of a system,” he said.