Healthcare As an Information Service - Dr. Geoffrey Rutledge, Co-Founder and Chief Medical Officer of HealthTap

DR. RISHI DESAI: Hi, I'm Rishi Desai. Welcome to Raise the Line. The popularity of online medical care has grown tremendously during the COVID pandemic, and new services seem to be popping up all the time to take advantage of a new level of comfort that both providers and patients have with this approach. But some companies have been providing virtual healthcare for many years. Today on Raise the Line, we're going to talk to the co-founder of one of the pioneering firms in the space to get his perspective on the current use of this modality and where it's heading. 

Dr. Geoffrey Rutledge is Chief Medical Officer of HealthTap, a leading virtual healthcare provider. He's been involved with the use of computer-based technologies to improve healthcare throughout his 25-year career as a physician, teacher, researcher, and medical executive. Thanks so much for being with us today. 

DR. GEOFFREY RUTLEDGE: Nice to meet you, Rishi. 

DR. DESAI: So maybe we can just start out by learning a little bit more about you and what got you first interested in healthcare, particularly in emergency medicine or EM. 

DR. RUTLEDGE: Thanks. Fundamentally, I am a physician. I had started as an undergraduate doing research in molecular biology, and realized that my real passion in life was about connecting with people and recognized that becoming a doctor would be a wonderful way to have a career reaching out and helping people individually. I do have a bit of a technology bent though and actually pursued further formal studies in computer science. After getting into practice, and teaching, and practicing medicine, I realized there was a huge opportunity to apply technology to make healthcare better, and that as a physician, I could reach more people building technology solutions that improve the way doctors give care, giving support for doctors and patients to have a better healthcare experience. 

DR. DESAI: What was the status quo like when you first entered the healthcare field with respect to technology? What was the landscape like at that time? 

DR. RUTLEDGE: Well, I have to admit, I did start practice before computers were in common use. Actually, I'll share with you that I initially built my first computer while I was still in medical school. This is before the Apple II was first released. I was very interested in technology and the use of technology in the process of care from the earliest stages, but medicine was entirely paper-based. Fax machines were state-of-the-art, and the new thing that swept through medical care in the day. Our processes in medicine have typically been quite manual and very paper-driven over the years. We've seen, of course, the advent of technology that was first applied for administrative and billing tasks. Naturally much of the industry has suffered from that origin, as technical administrative and billing payments support rather than direct clinical support. It's been my joy to see and watch the technology evolve to apply the technology to support the delivery of clinical care. 

Now, certainly, where my personal focus is, is using the technology to understand the processes of care to give knowledge-based and directed clinical support to doctors to give them  information. I guess I would mention, parenthetically, that healthcare really is, the delivery of healthcare is an information service. We think about the personal touch and the needed relationship the doctors have with other individuals. But in terms of the medical care and the actual treatment provided, it really is based on information. So computers are wonderful tools for putting the information together in ways, both collecting information, displaying it, showing it to doctors, and also inferring what the information means, and giving doctors information about the appropriate, alternative, or best possible courses of action for any given patient. 

DR. DESAI: I guess the part of that that's intriguing, especially now, is the inference part. Where do you think the technology stands right now with respect to taking information and inferring the meaning behind it? 

DR. RUTLEDGE: I think we're still very much at the early stages. There was a lot of excitement when the mandates for the motivations of the incentive programs for getting EHRs into clinical practice were enabled. We have now, through the penetration of EHRs in clinical practice, we're in a stage where we're collecting the information. What we've failed to do, or we're in the early stages of, is defining standards such that information is in standardized formats so that it can actually be used consistently, particularly across clinical systems. The bottom line is that there are demonstrations that it's possible to use the information in the EHR to make inferences and representations that show doctors the implications of the information in the system, but we're still in the early phases of the plan. At HealthTap, for example, when you do a symptom assessment, you'll see an example of this, where the information about symptoms, risk factors, and features of an individual, and their prior history, are brought together using a knowledge-based system to identify the possible explanations for a given scenario and given set of symptoms that someone has. That's just an example of how it's possible to do that. But collecting that information has to be done in a standard way if we're going to use such systems in a standard fashion across multiple healthcare systems.

DR. DESAI: How did HealthTap get started?

DR. RUTLEDGE: We started the company little more than 10 years ago when we recognized that there was an opportunity to bring healthcare to mobile devices. It was very early after the release of the first iPhones and tablets. Phones were really in the early stages of use. We had seen at that point, early use of phones for different kinds of transactions. For example, banking had gone to phones, demonstrating that it was possible to do secure things that people cared about, that had value, on their devices. At the time, there was absolutely no access to healthcare, health services, on mobile devices. We thought that there was a real opportunity to build a platform that would deliver, and enable doctors to deliver, healthcare through their devices. We set about building a platform, and a company, that would be able to deliver healthcare through mobile and electronic devices. 

DR. DESAI: Walk me through what the experience is like, both for the providers, as well as patients or users of HealthTap. What is that flow like for them?

DR. RUTLEDGE: You point out, if I may underscore, that it's important that the experience work for both providers and for patients. For this to be a successful service, it has to be something that both parties find useful and appropriate and effective. We've designed a platform that enables, on the consumer side, someone to gain access to information and support, and directly connect them with doctors. We've built an interface that's device-independent, so whether you're accessing this on a smartphone platform, whether it's iOS or Android, or whether you're actually using a mobile or web-enabled device—you can use a desktop or a notebook—the interface and the interactions are the same across all of those platforms. The idea is to make it self-explanatory, obvious, and easy to use, so a person with a health concern can simply sign in and ask a question. 

We allow freeform text questions to be asked, and what we do is, if we don't already have the answer to that question, you can send it to doctors, and the doctors will give an answer to it. But because we have so many questions already submitted, and so many answers from doctors already delivered, most of the time, when you ask a question on HealthTap, we already have someone before asked a similar question and the doctors already answered it. So you get an answer from a doctor immediately when you ask a question because there's a library. There's something like 3 million answers in the library already, from doctors. We've invited doctors. So on the other side, that is the first step, doctors have the ability to sign in and engage people by providing answers to their questions. I just say "engage people," but really, they're engaging in the health, or they're engaging in the information needs that people have. So that if people have questions about health, the first stop is to ask a question. We like to comment that people first go to Dr. Google, and ask their questions there. It's astonishing how many health-related questions are asked on Google every day. But the reality is that it's very hard for people to interpret or understand the results on Google, based on how trustworthy the source of the answers are. 

What we set out to do at HealthTap was create a place where people could get trusted answers. By having verified doctors give the answers to questions, people have greater trust and ability to understand the answer. The other thing that doctors give, of course, is answers that are appropriate in the context of the person who's asked the question. We like to joke that on WebMD, every headache gets turned into brain cancer within three clicks. It is true that when you ask about headaches, one of the causes of headache is brain cancer. But it's very easy to find the answer that's very scary and complex and difficult, even if that answer isn't relevant or likely to be of use to the individual. 

DR. DESAI: So, Jeff, one of the things with what you said is that different physicians might bring different opinions to the table. I'm just curious, for example, let's take a question like, "I'm pregnant, should I get a booster shot for COVID-19 vaccine?" Different physicians might answer that slightly differently, bringing up different studies, different points of view. Do you ever have a situation where a patient might read an answer to that, and then their physician might say, "Well, you know, that's not quite how I would have answered that question.” How do you deal with that? 

DR. RUTLEDGE: That's a really good point. What we've been able to do with this feature on HealthTap, this doctor question-and-answer feature, which is of course just one of the many things that we do on HealthTap—the first step before you access care is getting answer to your question. What we've done is we've reproduced what actually happens in the real world when you talk to a doctor. When you go and see your doctor and ask a question, you get one answer from one doctor. To your point, doctors do vary in their approach and understanding of various problems. If you were to ask three different doctors, you might find you got three slightly different answers to the same question. We've reproduced that, except now, on HealthTap, when you ask a question, multiple different doctors will answer the question. On the doctor side, one of the things they really enjoy doing is being able to read other doctors' answers because they learn from, and have their own information and knowledge supported, or confirmed in the process. It's an educational experience for doctors. 

But as a side effect of revealing other doctors' answers, when a doctor disagrees or has a different opinion, they have an easy method to express that opinion. If they think an answer is incomplete, a doctor can add a comment on the previous answer, so that it extends and complements the original answer. If the doctor thinks they actually have a significantly better answer than the one that's there, they simply enter a new answer, and the patient who asks the question gets to see both the first answer from the first doctor, and the second answer. The patient also gets to see who the doctor is. By looking at the profile, they can see the background, the training, the specialty, the experience, and the location, which allows them to interpret the different answers that the different doctors give. 

I've been very impressed with the degree to which doctors, when they see an answer they think is not the best answer for a person, feel really compelled to go and give the information to that person who asked the question needs. It's been wonderful to see that because in the end what you see is the range of opinions are expressed, but other doctors weighing in. 

I should mention that as part of the peer review process, when a doctor sees an answer that they do agree with, there's an agree button. When you hit the agree button, that gives the person that asked the question further confidence. When you have different answers, the doctors will agree with a better answer, and by seeing the answers and the result of the doctors' agreement with those answers, it becomes really obvious which answers are the ones that most doctors agree with, and which answers actually represent a more fringe, or different, or not-widely-held opinion. This is a unique characteristic of the question-and-answer feature on HealthTap. We've used the crowd to source the expertise, rather than having a single editorial board defining what is the right answer versus not the right answer. This allows us to have a broader range of topics, a much larger set of content, and a much more consistent, and overall meaningful answers to questions people ask.

DR. DESAI: Does a clinician's reputation score, per se, change? Let's say they've gotten lots and lots of positive feedback from the community, lots of agreement with what they're saying. When they go in to answer a new question, does that get reflected in terms of how their answer is weighed or presented to the reader?

DR. RUTLEDGE: That's a wonderful question, and the answer is, yes. When a doctor gives an answer, we understand the topics of every answer. The technology in our system, we have a comprehensive consumer-focused ontology of health topics. For each answer and for each question, we know what the medical topics are related to that question and answer. When another doctor agrees with that answer, the doctor who gave the answer gets credit for the topics in the question. We call this a “known for score”—the doctor becomes known for the topics that, when they give an answer on, other doctors agree with. This allows us to create a reputation score, we call it a “doc score,” for each doctor based on how often, when they give an answer, other doctors agree with it. Then we use the doc score to influence the ranking of the answers. When there's multiple answers given to a question, the doctor with the highest doc score will increase the weight of that answer. We also look at other things, like whether the answer was specifically agreed with by other doctors, so that when there's multiple opinions, we can present the opinion that appears to represent the consensus of doctors, rather than the individual opinion of an individual doctor. I'm very, very proud of this system that, at scale, helps people get answers from doctors. As I said before, this is just the first step in the journey on HealthTap to achieve care for a given problem or issue someone has.

DR. DESAI: One of the main competences, as you know, of physicians from the ACCME is around knowledge. It seems to me that this doc score would feed in beautifully into a person's demonstration of an ongoing maintenance of their knowledge-base. What do you think of that idea? 

DR. RUTLEDGE: I like it a lot, the idea of doctors expressing or exhibiting their knowledge on the site and helping people directly. We try to present incentives and rewards for doctors who are able to help people. The doc score is one of them. We also show doctors, for example, the number of people that their answers have reached. So we call it a “people-helped score,” which doctors really quite fond of. But on the learning side, we also enable doctors to learn about topics. One of the things I'm very excited to see happen is that, when a doctor sees a question that they don't know the answer to, we give them the ability to search the medical literature and learn about the topic of the question. As a result of spending time reading peer-reviewed medical literature and learning about medical issues, the doctor can earn CME. In fact, it's unlimited, the Category 1 CME doctors get for reading and learning about questions to better enable them to help someone, and in the same process, learn. One of the things that I'm very proud of, on the doctors' side, is that doctors are able to consistently not only help people, but learn in the process, and get rewarded by earning CME along the way.

DR. DESAI: Another major concern that's been raised with virtual health services is continuity of care—seeing different physicians or clinicians each time they go in to get checked out. How does HealthTap address that issue? 

DR. RUTLEDGE: It's also a very good point. Traditionally, I think you're right. Virtual care has traditionally been sort of transactionally-oriented, more like urgent care, where each time you go, you see a new doctor, and that doctor doesn't know you individually and isn't able to give you evaluation and care in the context of your everything else. That's just not possible to do in a single very short visit. 

What we've done in HealthTap was we've created something we call the Virtual Primary Care Clinic, where a person can actually choose a doctor, or when they meet a doctor in Urgent Care, if they like the doctor and that doctor works in the Virtual Primary Care Clinic, they can schedule an appointment with that doctor. So someone can choose and select a doctor who becomes their personal care physician, gets to know them, manages them and is available to them by schedule. We've also enabled text communication. Once you've established yourself with the doctor, then you can send texts to the doctor to ask about a specific issue or to inquire about a concern. The doctor can respond either by answering the question, by making a treatment, or by suggesting that actually what you need is another visit in order to sort out what to do in that care. 

We've established the ability to have a long-term, longitudinal relationship with a doctor that you've picked, that you get to know, who knows you, cares for you, and manages your health concerns over time. I think this is a huge advantage for people—particularly, those who don't have easy access to a primary care physician, or for whom their problem doesn't really require in-office care. When you look in primary care physician services, you see that the large majority of time, people who come to the office and have a visit don't actually need an in-person encounter. They need the time and the attention and the interaction with the doctor, but that interaction could be done equally well virtually. I'd point out that in some cases, the virtual interaction is even better. It's sort of like doing a house call. You get to see the person in the context of where they are, and learn—I'm often surprised how much I learn about a person's living situation by doing a video consult where I get to see where their home setting is.

DR. DESAI: Yes, that makes a lot of sense. I'm curious then, where do you see this going? What do you think are the big challenges in the next five to 10 years that have not yet been fully solved with respect to virtual healthcare? 

DR. RUTLEDGE: I think the reality is that ideal care integrates virtual and in-person care. Very clearly, there are people that, even if 85% of the time, that person is well and needs ongoing routine care that can be done virtually, there is a fraction of time that care needs to be done in person. There are certain manipulations or procedures or injections or treatments or physical evaluations and testing that simply need to be done in person. The virtual care, although it can handle the majority of problems that most people have, needs to be better integrated with the in-person world. When I first got started, I thought of virtual care as adjunct to in-person care, that it would be useful in between visits. We've evolved now to realize that it actually can be the first and the primary care, but still, that better integration of—when it's needed—transition to in-person care is this problem that needs to be solved. 

DR. DESAI: What do you think all this says about our overall healthcare system? Now that COVID has swept across the country and the world, where does HealthTap fit into this kind of new world order with respect to healthcare? 

DR. RUTLEDGE: Well, it's a longer discussion to talk about the American healthcare system and the the way in which it is broken up and healthcare is delivered. But I do believe there's a huge role for a consistent virtual care platform. It's astonishing how many people don't have a relationship with a primary care physician, don't have access to one. They view healthcare as something that, "When a problem occurs, then find a place to get the problem solved," as opposed to having someone to be with you during the journey of your life as you achieve, or seek and maintain, a healthy lifestyle and a long-term existence. 

I think, therefore, that in the future, everyone should have a virtual primary care physician as a starting point and as a guide, as someone who can orchestrate their access to other forms of care. By meeting someone who knows you, and understands you, and having that person be the first touchpoint for healthcare, that ensures that the care you get is the care you need. Right now, people self-select for the care they want. If they make the wrong selection—if you have chest pain and you go see a cardiologist, but your problem is gastrointestinal, or vice versa: you think you have a GI problem, and you see a gastroenterologist, you're getting the wrong care and you get unnecessary care. It's much better if you have someone who knows you, who can first figure out what care you need, and then give you a direction to the right, next step of care.

DR. DESAI: We're a teaching company and we love to fill knowledge gaps. I'd be curious to know if there's any topic that you think that our audience should be educated on, something that you think everyone ought to know. It could be anything that you've come across—maybe a myth that often is believed to be true, or anything along those lines. 

DR. RUTLEDGE: The most obvious and immediate answer, of course, is the misinformation that exist today related to the COVID pandemic. I don't know that we can solve that here in this venue, but I think the physicians have a role in conveying the magnitude of information we have about the safety and reliability of our current methods of managing COVID. If we could simply spread that information more effectively, and get people to understand and trust in their physicians that the steps we're talking about—predominantly, vaccinations, but also social distancing and masking—are incredibly important. That's the immediate and topical issue at hand. 

I think more generally, the idea that a physician can guide someone to have a healthier life. A physician can be a helpful resource to stave off or to prevent problems that otherwise are likely to occur, with very simple measures. Connecting with the doctor, and having a discussion about your lifestyle and your health, your goals in health and life, can be a very effective thing. I would make a distinction between the notion—we used to talk about the annual physical, needing to see the doctor for an annual physical. I think it's been fairly well-shown that the actual physical exam part of the annual doesn't accomplish anything measurable. On the other hand, connecting with the doctor to talk about your risks and your activities, and your health goals is something that can guide and direct you and actually help you achieve a healthier lifestyle.

DR. DESAI: That makes sense. I guess that might be a good point to jump into our final question, which is advice. We have seen a huge shift in terms of how people prioritize in-person visits—what they focus on, what they think matters—from even a few decades ago to now, or even one decade ago till now. In the midst of this incredible change in terms of how we think about healthcare, and what healthcare really offers patients and their families, what advice do you have for young healthcare professionals who may be just joining the field, in terms of how they should be thinking about their career, what they should be focusing on, and things along those lines?

DR. RUTLEDGE: That's also a very good question, Rishi. I think it goes without saying that doctors today are learning about how to use technology in their practice. Doctors coming into practice today are finding an environment in which the EHR is ubiquitous, and the access to services through mobile devices is now a routine part of care. I guess what I personally am impressed with, is that there's a fundamental nature of the doctor-patient interaction which is important we not lose. Some of the doctors that I've seen recently coming out of training have a more transactional view about the healthcare they're delivering. The important thing for doctors to maintain and to have, is to have the strength of their own profession in mind. The ability to be fulfilled as a physician is really predicated on the fundamental nature of being a physician, which is to connect with their patients. The technology actually enables those connections—particularly, as we think about the video side of connecting remotely. Doctors should recognize and value that they can be physicians, and have a fulfilling medical career connecting with their patients, by using video, in addition to all of the technology that supports the more informational and transactional aspects of delivering care.

DR. DESAI: That makes sense. I think that's a good note to end on, because things have definitely changed, and technology is at the forefront of what's driving a lot of that change. Thank you for bringing that up, and thank you for joining us today. 

DR. RUTLEDGE: Nice chatting with you, Rishi. 

DR. DESAI: I'm Rishi Desai. Thanks for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together.