A presentation earlier in the day suggested that the current paradigm for charging the patient for services rendered requires that the patient physically pass through the doctor's office. In industrial supply chains, a similar paradigm has become obsolete due to the globalization of manufacturing networks and the MRP systems that run them. When value is added to a product, which is akin to a physician applying his or her judgment and expertise to a patient's evaluation, no longer does that product need to pass through a certain factory domain for that value to be captured. Supply chains now emply 'virtual factories', where appropriate, where that value can be more efficiently captured and appropriately charged. Telemedicine is an enabler of the 'virtual waiting room'. A ROTI metric could be very meaningful and sensitive, but only if the charging paradigm can shift to one that a) values the patient's time as at least as important as the physician's time, b) embraces the concept of 'virtual' visits and waiting rooms, and c) exploits tools like telemedicine to help optimize the value of the time invested of both stakeholders.

The ROTI concept initiates what I hope will be a useful, potentially paradigm shifting discussion. Let me suggest a few areas for focus. First, how much information do we have on the patient experience? We have (powerful) anecdotal evidence like the case cited by Gene Sacco. What other evidence do we have on time expenditures and other patient impacts? It is common for hospitals and other providers to analyze the workflow from the provider perspective. How do patients experience that process? It would be helpful to have the patient's perspective on service workflow by following a number of patients through the experience of receiving services.

Second, it may be useful to distinguish regularized processes or behaviors connected with healthcare service delivery from ad hoc (or noisy) behaviors. A regularized process is one that flows in a predictable manner in relation to time and resources. I would suspect that patients suffer the kind of scheduling indignities that Dr. Sacco described when regularized processes either don't exist or are subject to frequent interruptions. The resulting chaotic mode of service delivery has consequences for both patients and staff.

A third area of attention may be the type of communication between service provider and patient. Rather than using the patient's time as a buffer for managing a chaotic process, it may be possible to use communications technologies to minimize the impact of necessary schedule interruptions on the patient population. This, of course, fits within the program of telemedicine.

It WAS an a-ha moment, a perfect juxtaposition of the macro metrics of efficient care and the micro reality of individual frustration. With so much energy and attention being funneled toward improving the "system" using quantitative data, it is instructive to remember that the system is comprised of millions of individual humans who live most of their lives outside it. Those on the inside should spend more time understanding the qualitative compromises that patients and caregivers have to make to participate in the system. Serious consideration of a broader array of innovative measurement tools like ROTI could make for a more balanced healthcare experience for all.

I had a similar "Aha!" experience at the session Joe mentions. So, I went back to the office and started handing out a survey asking patients to tell me 1) time of travel (estimate the total), time waiting (estimate time in lab as well, if needed) and 3) time with doctor. I then asked them to circle one of three choices regarding thier visit- "not worth the time" "time not wasted/no opinion" and "well worth the time I spent" I've only got a small sample so far, but as far as I can tell, the average round trip time my patients spend traveling to see me is 2-3 hours and they wait about 30-60 minutes. Most estimate that they get about 20-30 minutes of my time (follow ups only, so far). Every one of the 20 or so that have filled out the survey so far have said the time spent was "well worth it". I was shocked.

One problem with my crude effort to use ROTI as a measure is that the patients were all my patients, and were all here for follow up appts. The office was working well on those days. On the day when all hell broke loose, my assistant didn't even have time to hand out the survey. I'm trying to hand it out in our entire office, to all our patients, but some of my colleagues are getting nervous. We'll see what happens. Still, I hope to fine tune, and keep handing out this survey, so I'll keep you posted as I learn more.

As Neil Wasserman noted above, the health care establishment doesn't know a lot about the patient experience. The late Tom Ferguson was very much engaged in the idea of patients as collaborators in process improvement and lectured on it regularly. Some of the observations from his last effort (a collaboration at the University of Arkansas Myeloma Center) are in the process of being writen up and published. I can post the findings when those of us working on it finish editing. In the mean time, if you don't know much about Ferguson's work, here's a synopsis in the form or his obituary: http://www.acor.org/tom/Obituary.html

As a doctoral candidate in nursing, I have been examining how trust in providers is affected by technology-mediation. Our current knowledge about patient-provider trust is based on face-to-face interactions. Studies have found that behavior associated with increased trust includes: 1) greater perceived mutual interests 2) clear communication 3) history of fulfilled trust 4) less perceived differences in power with the trustee 5) acceptance of personal disclosures and 6) expectation of a long term relationship (Johnson 1972). The outcome of trust in patient-provider relationships is; 1) increased adherence to medical regimes, 2) disclosure so that the most applicable medical direction can be given and 3) decreased movement from provider to provider. The benefits are significant yet our medical system increasingly chips away at the ability of the provider to develop a trusting relationship with patients. I see ROTI as a valuable effort that will assist healthcare to determine where the balance lies. Technology can increase communication, thereby eliminating opportunities for trust to be degraded by an encounter such as the one that Gene Sacco experienced. Telehealth is an excellent opportunity to improve patient-provider interaction, however if we don't determine what the proper balance of ROTI is, there is a potential that technology will be misused. Health care providers are knowledgeable and have experience that they bring with them to the health care encounter. However, to get the greatest return on their time that has been invested in gaining that knowledge and experience, "bedside" manner is the catalyst for patients trusting what the physician tells them. I can equate it to treatment of osteopenia; even though calcium is the vital element, calcium does not provide adequate bone strengthening unless there is vitamin D to permit its absorption. It is important that we just don't forge ahead implementing technology and disregard what we have already learned. At the same time we have to think alternatively as to how we can accurately assess the best use of technology to improve patient care.

The responses to the original post on the ROTI concept have been fascinating and heartening. Dan's experience with follow up patients saying the hassle was worth it marries quite well with Kimberly's invocation of trust as the critical component of a patient provider relationship. Knowing Dan as I do, I can safely assume that he has the skills to establish a trusting relationship quickly and that this is a strong contributor to his patients' positive ROTI assessment.

So perhaps the challenge for the communications component of connected health can be succinctly stated the need to build and maintain trusting relationships recognizing the limitations of text-based messaging platforms. Think of the ROTI of an email exchange compared to an office visit if the trust factor was equal.

Another facet of this challenge becomes apparent when we realize that we already have too few providers to give each patient all of the time they need and that this problem will only get worse as the number of chronically ill continues to grow. We are experimenting with computer-based agents as tools to motivate and coach patients, hoping that a small number of the components of trust laid out by Kimberly can be automated in some way as a tool to eventually deal with provider shortages.

I am also curious if anyone has compared the expectations and attitudes of patients in the US vs. one of the European systems, where interactions with providers are much quicker and more mechanical. It would be interesting to compare outcome #1 from Kimberly's list (adherence) in these two populations as a function of perceived trust.

So those of us who are motivated to put in place tools to measure ROTI should also be measuring perceived trust as a corollary. It may be that the two values are closely related.

Doctors who feel that bedside manner is less important than their knowledge and experience perhaps don't understand the cognitive demands required for an effective bedside manner. Bedside manner is not niceness, it is a skill crucial for getting patients to actually take the pills that their doctor's razor-sharp intellect has chosen for them ("difficult" decisions like omeprazole for GERD or, even more complicated, prescribing a branded agent like Nexium instead of OTC omeprazole). It is interesting that the US healthcare system is willing to spend billions to develop a lipid agent slightly more effective than generic ones, but invests almost nothing in increasing the remarkably low compliance with the meds (I believe about 60% for Lipitor).

Face-to-face meetings are very helpful in providing doctors with information about their patients' goals and barriers to compliance. The way nonverbal as well as verbal information is transferred during such meetings is increasingly well worked out neurologically. Those who find the development of their own bedside manner not intellectually challenging enough might want to read recent research on the mirror neuron system, Paul Ekman's studies of facial perception, and so on.

HOWEVER, office visits certainly do not have to happen as frequently as patients need medication changes, single pieces of information, and the like. Telemedicine can greatly increase the efficiency of these interactions--and by minimizing the number of trivial office visits, provide more time for meaningful ones. Add to this the time saved by patients, often elderly ones, who must drive up to three hours for a routine office check, just to get a prescription renewed. Thus a system that allows doctors to be reimbursed for email interactions would benefit both doctors and patients. And even "bedside manner" can be squeezed through email's admittedly low band-width information transfer. A doctor's quick response through such a medium may make a patient feel much more cared for than a desultory pat on the arm during a rushed office visit.

Gene’s story is heart-breaking and yet to some small extent familiar to each of us. We have all sat waiting for care with no way to complain. We are simply so relieved when eventually seen we move on to the conversation at hand.
While this comment has spawned a conversation with many interesting points, I would like to comment on the possibilities for telehealth and its implications for trust. I agree with – that we must calibrate the appropriate use of mediated communication in health care delivery. One way to think about the ideal telehealth model, or simply health care model, is to think of it not as simply what technology could take over from a human but what technology is uniquely suited for and what humans are uniquely suited for. For example, it is fantastic to be able to ask a doctor a question asynchronously when the problem arises off hours; people have an easier time reporting sensitive information to an automated system versus a human being; and, computers do not “forget” information. At the same time, people are flexible and adaptive in ways that AI researchers only dream of for computers.
A well conceived health system is a hybrid one that will enrich care both in terms of outcomes and the patient doctor relationship by improving information exchange and maintaining a persistent between interested parties between visits. Virtual visits will complement and expedite care such that face-to-face meetings are fully informed, efficient and tailored to the patient’s needs and current situation. I grant that this is an ambitious view of health care. Still, if all else fails at least online tools will give us, as patients, a voice with which to complain.

I agree. There is a lot of low hanging fruit to improve ROTI for Health Care Customers (patients) with telemedicine. A few thoughts. If a doctor is running behind his schedule, the patient is either emailed or called on her cell phone to let her know the estimated time the doctor is available. The airline industry does this.

Also, I am surprised that I have my annual physical first and then have my blood tested after the physical with the results available only 1 week after my physical. The doctor is looking at my blood test results that are 1 or 2 years old during the physical. Why not have the patient come in 1 week early to get the blood test done first so the most recent tests can be evaluated during the exam?

There are times when I do not hear from my doctor’s office after the blood tests and I assume that no news is good news. My thoughts on this topic have changed. My father passed away 2 years ago with pancreas cancer. After his death, the doctor’s office called twice to schedule a follow up visit. If a doctor’s office can not track this event, maybe an unusual blood test reading may be missed as well.