Healthcare is evolving.

Sometimes it seems slow and Darwinian, akin to his description of a gradual accumulation of small variations over long periods of time.

However, Darwinism also allows that the speed of evolutionary processes can be influenced by a variety of forcing mechanisms favoring change.  Healthcare evolution can feel more rapid as a system and a workforce adapt to external variables even while maintaining a central tenet and mission.

In healthcare, a silver lining from the current crisis is that new pressures are dislodging old constraints as a matter of necessity. This will enable the success of innovative approaches that seemed inevitable, but never really managed to arrive. Similar to evolution, life and optimal adaptation find a way.

Telemedicine is an oft-quoted example in the current environment. With recent regulation relaxation on barriers to reimbursement, both patients and money are flowing into the space. And when money flows, business models and investment become viable where they previously weren’t.

New constraints will arise, but the field has undoubtedly shifted. Recalling classic operational dynamics, there is always a rate-limiting step influencing the rate law for a reaction or process. If one rate limiter slowing progress for telemedicine was regulatory restriction on reimbursement (thus discouraging business model innovation and viability), things have changed very quickly. The rate law, or accessibility to viable utilization, has dropped.

But this dislodging then raises the next set of rate-limiting steps that will dictate the pace of growth in this space. These other inputs —personnel, technology, behavior — are non-trivial.

Personnel
Personnel evolution in telemedicine will require collaboration to blend previous workflows into new ones and stitching technology organically and seamlessly together.

The rash on a child that needs an initial look can be handled via video call, as can the runner’s minor knee injury check to get a referral to a specialist.

But refining the way systems that accounted for a few hundred of these virtual visits annually accommodate 1000 or more a month requires new management, staffing, and further innovation. What support is required for the new scale? And what other types of visits might be enabled virtually if you have a mobile, mid-level community workforce with proper baseline data collection (supplying, for example, blood pressure ahead of a cardiology visit or HgbA1c ahead of a diabetes management visit)? Also, what limitations exist for different populations and how can these new innovations breakdown disparities rather than entrench them?  How personnel are distributed and tasked in the new system will profoundly signal how rapidly we can evolve this space fairly and equitably.

To manage any of this effectively though, technology must also transform.

Technology
The technology needed to drive rapid evolution has always faced unique constraints in healthcare. Initially, we’ve seen use of innovations drawn from other industries, as healthcare is long known to design technology for yesterday’s use cases rather than project and enable a future set.

This historical bias has largely robbed healthcare users — physicians, nurses, and supporting professionals — of the ability to even dream of a better reality for this evolutionary space. All of which presents friction and limits progress.

Indeed, this is not lost in the user experience.  Early technology-enabled engagements in telemedicine — from virtual office visits to remote patient monitoring (RPM) — feel clunky, usually worse than in-person experiences, and at best offer marginal improvements. Measured against no visits, as during the pandemic, they leave us with a grudging “it’s better than nothing” appreciation. This will persist for a while as we navigate to a new norm.

However, the rapid uptick in utilization has changed the way care providers think of the tool.  Instead of stating, “It can’t be as good as an in-person visit,” clinicians are asking, “What would make this as effective as an in-person visit?”  Further, as reimbursement and regulatory barriers have lifted, advanced business model viability is driving more investment. Transcendent breakthroughs will occur that elevate usability and leverage the transformative opportunities telemedicine presents. Hybrid data and video displays for enhanced decision making (physicians) and understanding (patients) will emerge. Heads-up displays and virtual curbside consults can be implemented with new technological infrastructure unconstrained by legacy systems that spread a level of expertise previously only witnessed within the halls of a hospital — but not beyond. All the pieces are here to be put together. Yet, as with the evolutionary progression arriving at opposable thumbs, there are final steps that will likely prove more gradual to complete the final piece to the puzzle.

Behavior
The watershed moment will be behavior change. There are innovative efforts to modernize behavior change support, but this is not a new factor and it has always been a difficult hurdle in healthcare.

What matters in the new environment related to speed of innovation is how quickly our behaviors have changed related to the current crisis, and how quickly we are getting both objective and subjective data on the viability of different use cases.

At a clinical level, telemedicine has historically faced resistance for tangible, if not misplaced, concerns. One often-cited risk prior to 2020 was a disruption to the primary care practice.

But telemedicine has reached an inflection point overnight. With the rapid, real, and unavoidable disruption to primary care practice from Covid-19, the metamorphosis of the primary care physician being able to interact through telemedicine was equal to that of the caterpillar becoming a butterfly.

To be sure, shifts enabling reimbursement helped enormously, but the speedy acceptance and command of telemedicine practice by physicians has also been impressive — so much that many physicians now cannot see a world without it existing. More importantly, physicians are envisioning practice where they can help shape how telemedicine technology and personnel are deployed for better care and health. Their innovation spirit is being unleashed.

Telemedicine is just one example of where necessity is rapidly changing modern healthcare practice, and it’s overdue. We have not had any reasonable growth ideas hit the healthcare market in over 20 years. The technological evolution seen on the administrative side has been largely me-too in nature and not designed around the unique constraints of healthcare. We’ve also learned that healthcare systems cannot operate in the future on a non-redundant supply chain.

There will obviously remain pressing issues for systems in an ongoing state of pandemic management and healthcare administration to ensure proper resourcing for the right care.  Further, as new technology, capability, and ultimately care delivery arise, ensuring fair and equitable access will not only be a priority, it will be a necessity to focus on.  The ramifications of scaling an inequitable solution will be magnified.

For clinical care, the dramatic shift in behaviors sparks a new reality for both patients and physicians. Innovations around how to effectively operate and use distance as an asset will be important, and adaptation will stem from physicians, patients, and system leaders. The health threat created an alignment of these three — dynamic personnel shifts, technology embrace, and significant behavior change — allow for rapid evolution and create opportunity for alliances across the care continuum. This is critical. For example, telemedicine can only be functional if it has a continuum to a physical space for when those interventions are needed.

Covid-19 is severe and life-altering. Out of its wake of deviation, a better overall system can emerge. Our ingenuity and resilience are our assets, but they require a willingness to adapt to succeed. Here’s hoping it happens more quickly in healthcare than in our own human evolution.