November 22, 2022

Designing new care models (Dr. Jay Parkinson)

Last week, Awell’s Partnership Lead Rik Renard and Guaranteed’s Head of Medical & Clinical Affairs Dr. Raihan Faroqui hosted the first CareOps hangout together with Dr. Jay Parkinson about designing new care models.

Dr. Parkinson is the founder of Hello Health (2008) and founder of the first virtual primary care company Sherpaa in 2012 (acquired by Crossover in 2019). He developed the skill set to architect platforms and care models for hundreds of thousands of patients and 700+ clinicians caring for employees of Apple, Microsoft, Facebook, Amazon and many other Fortune 500 companies. 

For this CareOps Hangout we gathered questions from the community ahead of time and structured our conversation around three themes:

  1. Building new care models
  2. Building and structuring a team
  3. Delivering high-quality care

Watch the recording of the CareOps Hangout with Dr. Jay Parkinson.

Quick CareOps recap

If you are already familiar with the terms CareOps and care flow, skip this section and feel free to go straight to the key takeaways.

What is CareOps?

CareOps is a set of practices and tools to build, operate and improve software-enabled care flows. It applies principles from agile software development, quality improvement and design thinking to healthcare processes.

CareOps brings people from clinical, operations, product, data and compliance teams together, overseen by strong clinical leadership. Ultimately, CareOps increases a provider organization’s ability to deliver higher quality care at lower cost and drive improvement cycles more frequently than its peers.

For more context on CareOps, read What is CareOps and why do we need it?

Isn't CareOps the same as clinical operations?

Clinical operations or clinops is a function that helps making sure care is getting delivered.

CareOps is a cross-functional practice to design, implement and optimize software-enabled care flows that power clinical operations.

What are care flows?

The central concept of CareOps is the “care flow”. At different care providers different terms are in use for this term, such as care program, care pathway, care plan, patient flow, patient journey, care journey, clinical protocol, care process, (clinical) service line, care process model, clinical workflow or even digital therapeutic.

In essence they’re all sequences of activities completed by a care team and/or patient to maintain or achieve a desired health status for that patient.

Care flows are often defined at the medical condition / population level: a care flow for “Anxiety”, “Type 2 diabetes”, “Total joint replacement with obesity for 65+”, “Menopause”, “Sexual health for LGBTQ+”, “Discharge after surgery”, etc. and can be patient facing only, care team facing only or include activities for care team and patient.

We’ve used “care flow“ as an umbrella term in the panel discussion.

Building new care models

Dr. Raihan Faroqui: If you could go back to 2012 and do anything differently know what you know now, what would it be?

Dr. Jay Parkinson: The thing that I would probably change is my naivety. And what In healthcare there are two ways to create a new concept. You can either create a great idea that should exist and try desperately to find the business model for it or you can find the business model and reverse engineering a really great experience. Me and many others erred, unknowingly and naively, on the side of creating great ideas in search of business models. And you can say like, well disruptive innovation doesn't happen without that type of mindset. But then you realize over time that like, I don't know if healthcare needs to be disrupted just yet.  I mean, it's not a disruption to get people to be able to just simply email their doctors and get a response in 15 minutes. That's not disruption. That's just incremental for something that's normal nowadays. So, I think I would spend more time creating a suite of incremental innovations, rather than trying to go all crazy trying to disrupt things.

"I think I would spend more time creating a suite of incremental innovations, rather than trying to go all crazy trying to disrupt things." - Dr. Jay Parkinson

Rik Renard: What's your take on all the point solutions emerging? So, should companies first focus on doing one disease very well and then spread out more broadly or should they start broadly from the beginning?

Dr. Jay Parkinson: Sherpaa operated for three years with one designer and two engineers and we built an entire platform to power virtual primary care. And what that means is virtual primary care and any primary care needs to handle roughly 2000 diagnoses, right? It's not just managing acne or diabetes, it's building an entire platform to support a wide range of conditions. And what I'm kind of afraid of in the industry right now, is the fact that so many digital health companies are building near the exact same platform. I think we should be focused on building out frameworks rather than single conditions.

Dr. Raihan Faroqui: It's hard to make primary care models profitable as One Medical has demonstrated. So, providing high-quality care is one thing, but how do you keep your profitability engine running as well?

Dr. Jay Parkinson: Have you ever read Fred Wilson's dental office software post from 10 years ago? Basically, there's a really flashy founder who raised $500 million to build out the dental software suite. They do a great job, and they're killing it. And with $500 million in the hole already, they need to get a 10x return for their investors. And now you're looking at a $5 billion valuation for that investor to feel like they hit a home run.

And so, then another company comes along and says, well, we're kind of going to Shopify this thing, so that any dental guy can kind of spin up a shop and get to town.  They do fine and then all of a sudden, a few years later, there's  an open-source version that pops up. And now all of a sudden that technology is a commodity. 

That's what I think has been the trajectory of all digital health, and definitely primary care. When margins are so low and your investment to go to market is so high, it doesn't make sense to be a 10x homerun for that investment. It's probably going to trade more like E-commerce and I think that primary care is not really a venture scalable type of company. That means we need more commodity-like platforms to power primary care because it's the same everywhere all over America, primary care is the same process.

"Primary care is not really a venture scalable type of company." - Dr. Jay Parkinson

Rik Renard: We’ve all seen virtual first care companies emerging and many of these companies raised a lot of money, but which one do you think will be the winners in five to ten years?

Dr. Jay Parkinson: The challenge is the funding mechanism for healthcare services. There's no crazy scale that is going to produce a 10x return for investors. The problem to me is the investment vehicle needs to be disrupted. There needs to be an investment vehicle for 3x return.

Our main investor at Sherpaa was O'Reilly Alpha Tech Ventures, Tim O'Reilly's group. And they kind of started the seed fund concept, many years ago, many funds ago. And when you're seed, you're right in a big way, and you're wrong extremely frequently. And so, what they discovered was, ‘okay, if an investment fund returns 3x, which is pretty much average VC. But it depends on a few 10x returns, can we reverse engineer that concept, so that we can guarantee 3x, so all the companies we invest in, are going to give us a 3x return rather than one 10 X and the rest shut down? That's what I think is interesting.

"The investment vehicle needs to be disrupted." - Dr. Jay Parkinson

Dr. Raihan Faroqui: There's this active discussion now amongst the investor and operator community that says that not all tech-enabled services companies are VC bankable. So, in your perspective, what service or care delivery models are actually VC scalable?

Dr. Jay Parkinson: Not many. If the human is the pesky bottleneck, it's going to be a real challenge. And the other thing is, I tweeted something recently about how in the.com, bubble, all these cool companies were each other's customers and that's a risk. What I would love to see is that sort of open-source platform that allows any doctor anywhere to spin up a virtual clinic. But I think the funding mechanism for creating something like that is probably not VC and I also wouldn't think that the market is ready just yet to have thousands and thousands of virtual clinics being spun up so that like investors could get excited about something like that. It's still pretty nascent, the concept of virtual clinics.

Rik Renard: Imagine there is someone in the room here sitting and thinking about building a virtual first care model, what's the advice that you would give to them?

Dr. Jay Parkinson: With Sherpaa our first round was $5 million and it took a year to integrate with Surescripts back in the day. At the same time, we were able to spin up a practice with two engineers and a designer. I think that now that there's a way to get services like that off the ground without even hiring your own teams. I would just see what off-the-shelf technology you can leverage so you can just prove that there's a demand and you can get revenue. Once you have revenue, you're in control. Right now, there's probably a suite of tools out there that can prove that people will pay you for care and that's all you need to do. And then it's an issue of not logarithmic hockey stick growth, it’s just a constant march upwards as long as there's enough and total addressable market and demand for the services your clinic is providing.

Building and structuring a team

Rik Renard: One of the main principles of CareOps is bringing together clinical, technical, product compliance, and data altogether to build and optimize care processes. While this is the dream and state, the reality is that there is still a lot of friction between a clinical team and then a technical and engineering team. How would you personally bridge that gap between those two teams?

Dr. Jay Parkinson: Our office in Sherpa was fascinating. It was in the back of the office. And then, on one side of me was the engineering team and on the other side of me were the doctors practicing. It was so wild because, in one ear, I was hearing people yelling about engineering, and in the other one hearing people you heard about delivering care. It was the funniest thing because they were right next to each other, delivering care, like innovating on this model. It was kind of a real-time innovation happening, but it was really about just the structure, the physical placement of where they were. I didn't plan it that way. Unfortunately, I wish I could say it was that much of a genius, but it was just what we got right. It's very interesting to be engineering right next to the physicians and you just iterate super fast.

Dr. Raihan Faroqui: With Crossover you delivered care to hundreds of thousands of patients, so how can you scale so big without impacting your quality of care?

Dr. Jay Parkinson: I think ofit like there's Facebook the platform, and then there's a Facebook group. Facebook groups are essentially a practice. It’s just a little pod with for example 5000 patients and three doctors. And all you're doing is duplicating those pods. Now, what's cool about those pods are they leveraged and pulled from the same standardizations, and that's the point of quote-unquote, the Facebook platform. It is to create those standardizations so that every little pod slash group can use those standardizations.  And so, it's pretty easy to scale. This type of stuff, it's not hard as long as you build the service around the concept of pods, which is the right way to go anyway.  When you have pods, you kind of falsely limit the population sizes. It enables you to facilitate and foster relationships between small groups of people rather than a large population working with a large group of clinicians.

Dr. Raihan Faroqui: How can digital help solve the care demand gap and clinical shortages, especially when we're thinking about structuring teams on the provider side?

Dr. Jay Parkinson: The widget traditional doctors are selling in the traditional world is the time slot: "I'm gonna sell you a 15-minute time slot, it's $20 copay, and then I get like another $100 from the payer". So, the only way to fix that problem is to either decrease the amount of time slots to free up more services or say, hey, Doc, you gotta work another 10-time slots today. There's no other way to fix that. What I think digital health can do is say, well, we don't really sell the time slot anymore. We actually sell value. But for that you definitely have to get paid differently and you definitely have to not sell time slots. 

It goes back to Sherpaa’s doctor-to-patient ratio, that was almost double of a traditional doctor. Oral conversations, you can't really eat much out of them but if you chunk up the process of care delivery into something like sending a patient 20 magic questions around  abdominal pain, and then just wait till they answer them it will only take me 30 seconds to read it and start making an assessment. Now I've just automated something that you do all day with every abdominal pain you see. When you start realizing that every single element of a doctor's day is pretty routine. It's pretty bread and butter. You're doing the same stuff over and over so why not automate that stuff?

"When you start realizing that every single element of a doctor's day is pretty routine. It's pretty bread and butter to scale your care delivery model." - Dr. Jay Parkinson

Rik Renard: The biggest cost of goods sold for care companies is actually the people. How do you think about outsourcing or building the team internally?

Dr. Jay Parkinson:  You don't need a huge team. I see companies that just raised $20 million and hire 40 team members to do this. You don't need that. At Sherpaa we got started building out our first pod with part-time designer and two developers. To me, the core people that you need are the architect of the vision, design, a couple of developers, and a clinician. That's how you need to get started.

Rik Renard: And for providing care, would you also hire everything in-house? Or would you then maybe think about using a staffing agency like e.g. Wheel, Openloop or SteadyMD?

Dr. Jay Parkinson: If it's just some random doctor doing some random gig, you're not going to get much different out of them. You've got to have an in-house Medical Group.  Now, if it's just doing 10-minute transactions to take care of a sniffle. Like I mean, any doctor can do that. It really does depend on the mission of your care model and what you're actually trying to do. If anything is complex or weird or outside the box like a traditional 10-minute transaction or quick order for an erectile dysfunction drug, it's just something that doctors don't know how to do and you really have to have them on the same team so that you can let them peek under the curtain of the innovation of what you're actually building.

Delivering high-quality care

Rik Renard: How do you best balance a standardized scalable care model? For example, with centralized protocols, but also allowing clinicians with some clever creativity and flexibility when seeing and providing care to patients?

Dr. Jay Parkinson: At SherpAa we standardized how you take in history, how you communicate a care plan, and how you educate the patient. Those are three big time-consuming things that doctors do over and over that should be standardized. What we did was we built those standardizations within the platform, and made it super easy for doctors to pull up those standardizations and fire them off to the patient and interact with the patient.  The theory was to, make standardizations super easy because every human being is lazy. So, take advantage of every human being's laziness with really easy-to-use standardizations and make customizations hard. That was the design philosophy we had for the care team side of Sherpaa. We just made customizations more time-consuming. Like, they can do them but at the same time, what you find is 95% of the time, it's just not worth it. Again, make standardizations easy, make customizations hard.

"Take advantage of every human being's laziness with really easy-to-use standardizations and make customizations hard." - Dr. Jay Parkinson

Dr. Raihan Faroqui: How would you design care pathways that increase patient retention, especially when it requires buy-in from the patient?

Dr. Jay Parkinson: One of the cool things that we did regarding buy-in at Sherpaa was that every order that a doctor made at Sherpaa was sent off to the patient. It wasn't sent off to the person fulfilling the order. It was sent off to the patient and the patient had two options, accept this order or decline the order. Why? Well if we want to prescribe a medication like Prozac, what we know is that 50% of those prescriptions aren't filled in the traditional world because patients haven't really been bought into it. Maybe we didn't do a great job communicating the value of Prozac and they're not really that bought in so they decline this care plan. What's really interesting about it to me was that that decline of a medication came back to the doctor's dashboard as an action item for them to jump back into the patient and say "Hey, you decline this plan, why is that?". The doctor then has an open conversation with the patient to reformulate and re-strategize and find a plan that they're totally bought into. Maybe Prozac is not the right solution and maybe they need need a referral to a local therapist instead. So the gist is: get the patient on board, communicate the plan, communicate the value of the plan, and get buy-in.

"Get the patient on board, communicate the plan, communicate the value of the plan and get buy-in before you just want them to do what you want them to do." - Dr. Jay Parkinson

Dr. Raihan Faroqui: Tell us more about your challenges dealing with the medical community. How do you get them to buy into your models or ideas? Any tips?

Dr. Jay Parkinson: At Sherpaa I was very vocal about our mission, vision, how we work and what we do. It resonated with doctors, they would reach out and we would hire them. When Crossover acquired Sherpaa we suddenly had 700 doctors so we needed to do something else. This are two different sort of strategies.

When you're just getting started with something new in the space, write about it. Go nuts. Every good thing that's ever happened to me in my whole entire career is because I wrote something and somebody read it. It's mind-blowing. That's why I write. That’s why I'm on Twitter. That's why I’m on my blog. That’s why I’ll be writing a lot in the future as well. Get people on board.

"When you're just getting started with something new in the space, write about it. Go nuts. Every good thing that's ever happened to me in my whole entire career is because I wrote something and somebody read it." - Dr. Jay Parkinson

What we also did at Crossover was carving out the doctors into two separate groups: virtual-only and physical docs. We didn't make them do that. We just discovered that 10% of them were like "Hey, we just want to do virtual only". And it became another pull, rather than a push. So, we gave people the option and it resonated with 10% of them. Problem solved.

Rik Renard: You can track outcomes like PHQ-9, capacity utilization, patient satisfaction, but how would reward or penalize your care team members if they do or do not meet specific targets?

Dr. Jay Parkinson: Once something becomes a metric, it ceases to be a good metric because humans gain the system to meet the metrics. So I don't really believe in rewarding or penalizing care team members based on specific metrics. What I've found is that the most important thing you can do is measure them on how many standardizations they use, not the outcomes they get. Outcomes are just really gainable.

Rik Renard: You wrote a blog post on the fact that care looks very similar to a project that needs to be managed. Can you elaborate more on that article?

Dr. Jay Parkinson: The most basic way to say is every health condition is a project to be managed over time. The widget the doctor sells is oral conversations, typically in exam rooms. And if you had to deliver on a life-changing project at work that you knew would take a year long and you could only do it by setting up a meeting with the project lead for 15 minutes every three months, you're never going to deliver on that project. The management of a condition needs to be more like building a web app or throwing an event. It's team-based. It's collaborative. There's a single source of truth. There are purpose-built tools that are online in the cloud so that every team member has access to every moving part of that project. The design and structure of technology to support managing health conditions needs to look more like Basecamp and Jira rather than traditional EMRs.

"The design and structure of technology to support managing health conditions needs to look more like Basecamp and Jira rather than traditional EMRs." - Dr. Jay Parkinson

It's the same thing as Photoshops existed since the early 90s and Figma came along. At Figma's core, it was designed for collaboration, a single source of truth for the team. At Photoshop's core, it's a single source of truth for me. I got to export it to a PDF for somebody to look at it, or I'll send you the file and now there are 900 different sources of truth. That, to me is the problem with traditional clinical tech in healthcare. It's not designed at its core for today's collaborative workflows. Adobe bought Figma because they knew that, at its core, Photoshop is not this and it never will be that because it's flawed from the get-go. So, we need to spend billions and billions and billions to acquire something that's actually got the right core.

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Can't get enough of Dr. Jay Parkinson? He just launched his new company The Future Well  which leverages 15 years of experience to architect tech-enabled, human-powered care models. So if you're building new care model and want to do things right from the beginning: get in contact with Dr. Parkinson!

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