Flip No. 14

Cut down on unnecessary patient visits

Use big data to decide whether or not patients should come into the clinic.

By Flip the Clinic

An overwhelming number of patients visit the emergency room each year for conditions that could have been handled elsewhere. These unnecessary visits cost $14 billion annually. Part of the problem is that it’s hard for patients to know how serious their condition is or how to treat it without an expert opinion.

A web and app-based symptom checker, called Symcat, hopes to help cut the overuse by guiding patients to the emergency room, clinic, or bed, depending on their answers to a series of questions.

Pulling from 60 million patient records, Symcat calculates symptom-disease frequencies and then squares them against a patient’s symptoms, demographic profile, and medical history. The whole process takes less than 60 seconds. The result is a list of possible conditions, ranked by likelihood. Based on the outcome, a “find care” button makes recommendations about what kind of treatment to seek (if any) and then links patients to an appointment scheduling service. In 2012, Symcat won the Robert Wood Johnson Foundation’s Aligning Forces for Quality $100,000 Developer Challenge.

Symcat founder Craig Monsen, who attended medical school at Johns Hopkins, believes big data can make a big difference in the clinic. And its uses, he believes, go beyond just whether or not patients should come in for a visit. Health care providers have long been the gatekeepers to treatment, diagnosis, and medical specialists. Symcat, says Monsen, can help give patients more decision-making power. Patients choose care for themselves using both Symcat and their care provider as consultants. Providers, meanwhile, get fewer superfluous visits and could be better informed about a patient’s symptom history when they do come into the clinic.

Here are four ways that a robust symptom checker like Symcat might be used in the clinic to cut down on unnecessary costs and streamline the patient-provider interaction.

1. Learn about a patient’s detailed symptom history before a visit.
With a bit of information in advance, the clinic can prepare the appropriate exam room ahead of time.

2. Check medication interaction.
When a new prescription is written, Symcat will check to make sure that all the patient’s medications play well together. If no negative interaction is found, the new medication list is automatically pushed to the electronic medical record.

3. Know when to follow up.
If a patient is sick but opts to stay home based on Symcat’s recommendation, the patient can send their symptom information to their physician, who will follow up in a few days.

4. Stay on top of disease risk.
Patients can opt to send their heart disease risk calculator scores (more disease risk calculations, for conditions like kidney disease, diabetes, and cancer, are forthcoming) to their health care provider. The next time the patient goes to the clinic, the physician can follow up on the score.


  • Susannah Fox

    Symcat is intriguing, for sure, and would help the estimated 1 in 3 US adults who say they’ve gone online to try to figure out what health issue they have (Pew Research Center: Health Online 2013). When I tried it, I kept wishing for a pop-up nurse, like they have on the Lands End website and other consumer shopping sites. I mean, as long as we are dreaming!

  • Susannah Fox

    I shared this “flip” on Twitter and it generated quite a few responses. I’m hoping some folks will make the jump to comment here, but just in case they don’t, here’s a link:


    And a sample of replies:

    “I think it will increase visits”


    “without doubt. Diagnosis is a commodity, using big data to arrive at one is inevitable”

    “Yes – more quality info online is better. Problem I see is liability for provider or physician if something goes wrong.”

    “Only when it’s embedded into daily activities & becomes seamless to use. Short of that only offer incremental savings. The challenge is the balance shift in owning the commodity; today hospitals/clinics, tomorrow customers. Not to mention how it changes as we move from pathway medicine to precision medicine.”

    “I believe so. I was a huge advocate for symptom tracking when I worked in mental health. TONS of useful data to discuss. And if clinics can afford analysts (or recruit volunteers!), they can spend QT with the data & really analyze patient health.”

    “In British Columbia, not an automated system, but you can call a nurse line to discuss symptoms etc. can also use @medeo where can see a doc via video. Perhaps this also has possibility to reduce ER visits? also @RACEconnect1 in British Columbia. GPs can call 1 number 2 access specialist advice. Helps prevent unneeded referrals.”

  • http://www.nickdawson.net Nick

    I love this flip. There are some really powerful things embedded in the Symcat idea. In particular, the idea of computer-aided diagnosis seems like something we should be actively working towards. To that end, I’d challenge us all to think about some assumptions and goals.

    First, are we still putting the onus on the wrong resource?

    “An overwhelming number of patients visit the emergency room each year for conditions that could have been handled elsewhere.” – I challenge the idea that an emergency room is an inappropriate place for some levels of care. Why not build ERs which can handle all levels of care, with appropriate resources and costs? Patients chose the ER because its represents a ‘desire path’. It’s open 24/7 and it doesn’t require an appointment.

    Setting aside the ER example, we still need to consider if we are giving patients a complete toolkit. Put another way, is it reasonable to think most people will consult an app to figure out which healthcare delivery options is best for them? Telling me I should go to my primary care doctor is well and good, but doesn’t do anything to reduce the burden of getting in to see that doctor (online scheduling, long wait times, lack of appointment options, etc). That’s just another way of making patients fit the existing system. Why not build a system which can respond timely and appropriately to any need?

    Least I sound too “yes but…”, I wholeheartedly believe in the inevitability of computer-aided and computer-automated diagnosis. I’d posit, if we are to proverbially skate where the puck is going, we need to accept the idea that apps, sensors and in-home devices will make it possible for most people to diagnose at least common illnesses entirely on their own.

    There are commercial products coming to market this year which provide in-home rapid strep testing which is every bit as reliable as what is used in doctors’ offices.

    Once a service like Symcat, or similar, can reach the same level of accuracy as a physician, doesn’t that start to truly flip the model? Then you come your provider not seeking a diagnosis, but seeking a consult on treatment options. That’s a massive savings in time, steps and arguably cost. I can imagine Symcat collecting patient data and offering a reasonable, accurate diagnosis to both the patient and the provider in real time. Then a provider says “yep, I agree, here’s the eScript for the appropriate med.” There’d be no need for an office visit at all and the entire process may not take more than 5-10 minutes from both parties.

    Pie in the sky? Could never happen because legal/HIPAA/management/etc? Ask a record store, travel agent or mailman about their businesses.

    So my take is a resounding “yes!” this is something which not only should work to reduce costs today —particularly in the pragmatic ways outlined in the post —but is a harbinger of what will inevitably come in the next ten years. And that future vision is the kind of thing that really flips the relationship, the visit, and the clinical experience.

    • Shelley V. Adams

      Nick, I agree the question of whether people would use an app for this purpose is absolutely key, but I have to argue with your statement about the ER representing a ‘desire path,’ especially as it relates to behavioral health (i.e., mental health and substance abuse). People experiencing, or intervening in, a behavioral health crisis don’t go to the ER because it’s open 24/7, they go to the ER because they’re desperate to find help and don’t know of any other place to go.

      It’s also a situation in which if there’s another place to go, like a 24-hour behavioral health center, it is–in terms of outcomes–the *better* place to go. They’re growing in number because they save money for the big healthcare systems that they’re part of, but they aren’t doing that just by avoiding the financial cost of the ER facility. They’re doing it by avoiding the psychological cost of the ER experience while either getting a person stabilized and connected to follow-up care or, when that isn’t possible, finding space for that person in an appropriate treatment facility.

      Would it be better if this happened when someone experiencing a behavioral health crisis goes to the ER? Absolutely! But until the mind and the brain are treated as one, it isn’t likely, and until then, an app that can point people who are desperate to find help to another place they can go could have a big impact.

  • http://cancergeek.wordpress.com Cancergeek

    First, I have to agree with Nick. Great points. Thanks to Susannah for highlighting this flip on Twitter.

    Next, I believe there are some additional items to be considered.

    As stated above, “…founder Craig Monsen, who attended medical school at Johns Hopkins, believes big data can make a big difference in the clinic.”

    This is a good springboard into reducing burden on a hospital or healthcare system, but again, the problem is taking an inside-out approach to healthcare versus an outside-in and beginning with the benefits and value to the end user, the people living within a community. (patients, consumers, users of healthcare, whatever the hot name of the day)

    An app and big data allows the playing field to be leveled between those that seek care and those that provide care. No longer is the knowledge gap part of the problem. The gating items now move to access to care and what is the value for that access?

    If an app and data can provide me with a diagnosis, ail it allow a change in the current healthcare business model to change? I should no longer have to wait for tissue or lab confirmation, just move me along to the next step in the process. (preferably remotely or face to face, based on my choice) So if I value this, then what am I willing to trade (pay) for that value? Or since diagnosis is typically a loss leader for healthcare systems, will they be more likely to allow that control to move into the hands of people within their communities and focus on the right treatment at the right time? (time will tell)

    The next movement may not be about big data, but about small data. Personal data.
    Symcat presumes the 80/20 rule as does most things in healthcare. We can force a majority of people to fit into a process that facilitates the production of healthcare. The more care we produce, the more we can collect.

    Yet the future is less about pathways and more about precision medicine. How do I and care providers understand the story of me, based on my habits, my choices, and my genetic makeup? Once we understand my personal data, then how do we use it to get me the right care, at the right time, the very first time? That is the level of access I want, and I value it, so how do we position that into another new business model?

    More importantly, as Nick highlighted, this is all within the confine of our current healthcare system. What we need to begin discussing and realizing, is that the break and fix of the big box department store hospitals in not the future. In my opinion, redesigning an “ER” is not the answer.

    I believe the future needs to blur the lines between traditional hospitals and our living community. Everyone in healthcare likes to use the terminology “patient engagement” as a buzz word, I challenge that it needs to be more than engagement; The care, health, and wellness need to become embedded into our everyday life.

    Care needs to become a simple choice and melt into the background of our daily habits. Like brushing our teeth, eating, going to work, and sleeping. Checking our phones every time they buzz, beep, and ring. It needs to be that easy.

    Healthcare’s largest commodity is our intellectual property. So why not use it and develop a new business model?

    Move into the community and begin to work with local restaurants to develop healthy choices. Add a wine pairing. Work with local employers and businesses to reward the community for making smarter choices when they shop. When you buy fruits and vegetables you get rewarded versus pizza and beer. Allow those rewards can be put back to use towards “health, wellness, or care” that someone needs during the year. When one needs to seek care, maybe it is as simple as going to their living room to meet with physician, printing a splint on a 3D printer, going to mailbox to get a device to connect to phone to do yearly screening exam, and the list of dreams goes on.

    In essence, the balance is shifting to where it originally resided, with people living in the community. Technology forced physicians and hospitals to build large boxes to house all of the big and expensive equipment. Technology is now allowing people to have access to it in their pockets, living rooms, social gatherings.

    So alas, it allows the opportunity to generate a new business model. One that rewards access based on the value provided as determined by the end user, the person that seeks care, wellness, and health.


  • DataScientistKeepin’ItReal

    I think this is a good problem to solve, but this is an over-engineered solution. What about an old fashioned triage nurseline? Doesn’t that work better? A nurse can hear your symptoms, and tell you if you’re ready to head in to an ER or clinic, or stay put at home. We’re too obsessed with buzzwords like big data. Nurselines can solve this issue now, and in a relatively scalable, low cost way. We could even enhance the Nurseline with a symptom checker tool, and make their diagnosis process easier. That seems like the right focus for this problem.

    In addition, I’m not too enchanted by the big disclaimer at the bottom of Symcat’s symptom checker. Call me back when you’re willing to stand behind the medical power of your tool — I’m not going to use something like this until the fine print aligns with the marketing material.

  • Thomas Goetz

    Great comments! Technology is definitely not a cure-all, and we have been wary, as we work on Flip the Clinic, to avoid just asking technology to take care of a problem – as we all know, it doesn’t work that way in healthcare. But there’s no reason not to demand that healthcare adopt useful technologies that align with our goals (and vice versa – that technologists turn their skills to healthcare!).

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  • M. Swift

    Patients need a personal doctor with personalized care so their caregiver csn decide if they really need to go to the ER unless it’s a real medical emergency. Heart attacks, stroke, labor, trauma, abnormal bleeding, SOB, chest paIns, or the worst pain you ever felt in your life are some medical emergencies.