January 23, 2017

Is this the primary care office of the future?

Daily Briefing

    Last week, a San Francisco-based tech startup called Forward opened its first clinic.

    The founders, Ilya Abyzov, a former Uber executive, and Adrian Aoun, a former Google executive who focused on artificial intelligence, designed the physical location with a sleek, modern image in mind—"Imagine a doctor's office that feels more like an Apple Store," Aoun says.

    But under the hood is a suite of technology that Abyzov and Aoun hope will transform health care. Aoun says, "We are going to try to build the operating system for health care."

    The tech

    According to Business Insider's Melia Robinson, when patients arrive at Forward, they check in on iPads and step into a body scanner. Within a few seconds, the scanner measures height, weight, body temperature, heart rate, and blood oxygen level—and uploads the data into Forward's custom-built EHR system.

    In the exam room, a wall-sized touch screen displays the biometric data as well as other elements of a patient's medical history. Meanwhile, Forward's software mines the data for possible issues and highlights them on the screen. As the doctor and patient speak, a microphone records the conversation and software pulls out relevant content, automatically adding it to the patient's record. New patients also undergo genetic testing, and the clinic has lab facilities and a pharmacy on site.

    Forward has put a lot of effort into improving patient experience. Doctors use cutting-edge tools such as an infrared camera that makes it easier to find veins and a custom-built stethoscope that works through clothing. And the company also has swapped out the typical patient robes for workout gear, intended to be more comfortable.

    Forward's approach also emphasizes remote monitoring and analytics. The clinic sells remote monitoring devices, and the company's software crunches the data so doctors get alerts when issues arise. Forward also employs medical scribes, enabling doctors to spend more time during visits speaking directly with patients instead of taking notes.

    The business model

    Forward doesn't accept insurance. Instead, patients pay $149 a month, billed annually, for unlimited access to doctors, a range of basic lab and diagnostic tests, travel vaccines, and even some prescriptions. This approach, which is known as direct primary care, isn't unique. But Aoun hopes it—along with Forward's proprietary technology—will help doctors emphasize prevention and prompt patients to become more involved in their health.

    Aoun also hopes a focus on software and efficiency will help doctors provide better care—and that the model will foster an ongoing relationship between provider and patient, rather than a "once-and-done" visit. "The rest of the world is failing doctors, especially engineers. We've built them the [worst] software you can imagine," he says. "Doctors just need better tools that put all the information they need in one place and then build an algorithm on top of it."

    Ultimately, Aoun says, investing in new technology and tools will pay off. "The marginal cost of all this technology is not that high," he says. "It's less than the doctor's time."

    The company aims to treat about 10,000 members from its San Francisco location and already has plans in place to build a second facility.

    Devil is in the details

    Forward seems to have a lot going for it, including venture capital support from high-profile investors including Eric Schmidt, the executive chairman of Alphabet, Google's parent company. But experts say its reliance on technology and its unconventional business model are not necessarily a winning combination.

    Zak Holdsworth—CEO of Hint Health, a company that works closely with direct primary care practices— says Forward may be too expensive for many patients, although Aoun hopes Forward's membership fee will come down over time. Currently, Forward is offering some free or subsidized memberships to those who can't afford the price.

    And Jeffrey Gold, a Boston-based physician who started a direct primary care practice, says Forward's model will work only if it builds a sustainable membership mix of both high-need and healthy patients.

    Gold also cautioned that advertising the service could be difficult. "It's not easy getting people to pay for a product they have been accustomed to having someone else pay for, like an employer," he says. And while Aoun says Forward aims to reach a broad mix of members, regardless of age or health condition, Fast Company's Christina Farr writes that the company seems "to have been designed with younger users in mind"—and millennials, Farr adds, "aren't the easiest demographic to court."

    On the clinical side, some experts are concerned that Forward's model will encourage excess utilization and testing. As Farr writes, when "doctors look too closely for diseases by tracking an extensive range of factors, they almost always find something," which can spur treatments and additional testing that isn't necessary—or even is harmful.

    Others are skeptical that Forward's technology will produce meaningful efficiency and clinical gains. Abhas Gupta, a doctor and founder of the health startup Calyx, says technology is "great marketing but [not] necessarily tied to outcomes" (Farr, Fast Company, 1/18; Helft, Forbes, 1/17; Coren, Quartz, 1/19; Buhr, Tech Crunch, 1/17; Robinson, Business Insider, 1/17).

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