How Can Innovation Save Primary Care? Podcast with Dr. Ronald Dixon

I am an Internal Medicine Physician. I started training in 1998 at Mass General. And after training in my last year, I did a lot of ICU care and I was really fascinated by the difference of working in the ICU, and then following up in your Primary Care Clinic. So in the ICU I would walk in and everything would be set up for me. I’d have the patients that I needed, to see to be rounded on first, those were all highlighted on a board in front of me. When I walked into the room I would be able to see the vent settings and be able to adjust them, I’d be able to see all of their Hemodynamic Parameters, they were very clear for me to visualize and then make changes on, and then I’d see the nurses notes. And I’d have to write a little quick note about what I’d done with that patient and then move on to the next patient that was prioritized for me by the nurses.

 And then I go to Primary Care Clinic and I would be doing pretty much everything, granted I had a Medical Assistant. But I would be trying to gather data about patients that was really relevant to their home life and I didn’t really have any of the data points. The patients that would be coming into my office would come one by one with no real prioritization and often I’d be missing data that would allow me to best take care of them.

 So I was kind of comparing and contrasting what was happening in the ICU versus what was happening in my clinic and that’s really what brought me to this idea of, well, why don’t we try to get some information from patients into setting that they’re in from their home and why do we focus so much in office, but especially in outpatient Chronic Disease, when it’s really the things that patients are doing at home and the data that you need from the home that’s going to help best manage that. And that led me down the path of really Primary Care Innovation. I was fortunate to be at Mass General and to be supported with a fellowship that allowed me to really investigate this idea of using technology to engage patients.

I started doing some things that were probably seen as disruptive. I started emailing patients and sending them question sets about their Chronic Disease, like Hypertension Diabetes. So the same kinds of questions that I have asked them in the office, I’ll just send them on email and this was before Hippo, it was like 2002-2003, and patients loved it. And I thought I was doing a better job of managing them and they were avoiding visits. And then I got in a little bit of trouble because of course I was taking revenue off the table for the practice. That made me even more kind of interested in the methodology and this idea of getting data from patients where they are and making your practice more efficient by doing so.

I was able to collaborate with some people at Mass General, some nurses and some other doctors to do some studies about this. And we tested things like Remote and Monitoring back with the BodyMedia device around. If you look at skin impedance and you try to get people to increase activity, “can you affect things like blood pressure and weight”? I started looking at Telehealth, specifically video visits. We did actually the first study of a video visits versus in person visits in a Primary Care Clinic while I was a MGH in Beacon Hill. And what we found that was really interesting was that it doesn’t save time but you can still make the same diagnosis, so you can still do the same E&M. But at the time it was so important to try to take things off physician’s plates, it was already, 2009-2010. We were already overburdened with the EMR. And I was getting overburdened with patient gateway messages, these long form messages that patients would send.

 And so that’s what led me to really think about Asynchronous Communication and then how can you really formalize that? And I developed actually a Company and with the help of the Mass General was able to launch a platform that allowed for patients and doctors to communicate using question sets. And instead of the patient coming in for a follow up diabetes, the question set would go out after 30 days and the patient would answer it, and then it would be returned to the clinician to make a decision. And we’d put a patient’s liaison, who was a nonclinical person in between to follow algorithms, just to let the doctor know if he or she needed to make an action.

So really this idea was to use technology and use nonclinical navigation type personnel to help make the doctor’s life easier. And that went well, we scaled it through the hospital, with the help of certain incentives from the Mass General. And we were doing really well over 60 different conditions. And there was a potential of a spin up business. And then Epic came along and said, “we’re going to take care and do all of that”. And I ended up leaving Mass General and went to work for Google Verily on a Digital Diabetes Company called Onduo. And probably two years into it, I got a call from some investors who had been looking at this Company, Healthcare 360, and they called me back and it was during the pandemic and said, “We’re really still interested in what you’re doing, we’d like you to bring that to another company based on Austin, Texas called Remedy”. And so I did that.

I left Verily Onduo, ended up going to this company called Remedy, which is now rebranded into something called CareHive, that I’m now running. So this is the original thesis of using technology to engage patients outside the office, leveraging nonclinical providers, to take burden off of primary care. And then I think the third piece of Asynchronous Data is Quantitative. So when you ask question sets and you answer yes or no, and how do you feel one to five? That Quantitative Data is very powerful because you can use that quantitative data to become predictive and then start understanding who needs to be escalated to what, when and who does need to be escalating, can simply be followed using technology and lower level navigators. And that’s really what we’re doing at CareHive.