{"id":136,"date":"2016-07-25T12:50:02","date_gmt":"2016-07-25T19:50:02","guid":{"rendered":"https:\/\/blog.sprucehealth.com\/?p=136"},"modified":"2023-10-26T06:24:15","modified_gmt":"2023-10-26T13:24:15","slug":"spruce-visits-build-spruce-visit","status":"publish","type":"post","link":"https:\/\/sprucehealth.com\/blog\/spruce-visits-build-spruce-visit\/","title":{"rendered":"Spruce Visits: How Do We Build a Spruce Visit?"},"content":{"rendered":"

Part one of our series on Spruce Visits explored\u00a0what a Spruce Visit is<\/a> and why we’re so excited about their power\u00a0to contribute to\u00a0efficient, high-quality medical care.\u00a0In case you need a quick refresher:\u00a0a Spruce Visit\u00a0is an\u00a0asynchronous\u00a0telemedicine encounter\u00a0that\u00a0uses an\u00a0evidence-based, condition-specific\u00a0algorithm to collect\u00a0a strong initial history and physical exam from a\u00a0patient and\u00a0provide it in an easily reviewable format to a\u00a0treating physician\u00a0or other care provider.<\/p>\n

Spruce Visits do no diagnosing, treating, or other medical decision-making of their own, but it goes without saying that their underlying algorithms need to be of the highest, unimpeachable quality in order for them to be safe and useful in patient care. In this article, we’ll discuss in detail how we build each Spruce Visit and why we think they represent a gold-standard in telemedicine that you can trust to help you care for the patients\u00a0who trust you.<\/p>\n

An overview of the process<\/h2>\n

Every Spruce Visit goes through the same creation and maintenance process, which we’ll go through step by step below. Here’s an overview:<\/p>\n

    \n
  1. Complaint\/condition\u00a0selection<\/li>\n
  2. Framework generation\n
      \n
    1. Literature search and evidence review<\/li>\n
    2. Differential diagnosis\u00a0formulation<\/li>\n
    3. Determination of important\u00a0history and physical exam items<\/li>\n<\/ol>\n<\/li>\n
    4. Algorithm\u00a0creation\n
        \n
      1. Draft generation<\/li>\n
      2. Review by expert physicians<\/li>\n
      3. Review by expert copy editors<\/li>\n<\/ol>\n<\/li>\n
      4. Ongoing feedback and maintenance<\/li>\n<\/ol>\n

        1) Complaint\/condition\u00a0selection<\/h2>\n

        \"visits\"<\/p>\n

        Each Spruce Visit is tailor-made for a particular medical complaint or condition, so the\u00a0first step in creating a new Spruce algorithm is to define exactly what type of patient presentation it will address. One class\u00a0of patient presents for\u00a0a specific complaint (e.g., “cough”), and we have constructed algorithms that address many such common symptoms, each with\u00a0a broad and thorough consideration of possible underlying pathologies. Other\u00a0patients, however, are best served when considered by diagnosis, such as a diabetic patient\u00a0or a patient with known psoriasis. We also build\u00a0algorithms for these patients,\u00a0with the more bounded nature of the presentation allowing us to dig deep and ask important, disease-specific questions: Has the diabetic patient had symptoms that might indicate undetected hypoglycemia? Has the psoriatic patient had new joint pains that could be inflammatory\u00a0arthritis? We also actively\u00a0collect expert opinion on\u00a0potential new\u00a0complaints and conditions\u00a0from physicians who use the Spruce platform, so our set\u00a0of available algorithms is always evolving and always based on real-world medical practice.<\/p>\n

        2) Framework generation<\/h2>\n

        Once we’ve picked a complaint (or condition) to target, we build what we call a “framework” around it. The\u00a0framework is a collaboratively-edited document that is developed\u00a0by the Spruce medical director and our expert consulting physicians, and it directly informs\u00a0the\u00a0algorithm that will eventually be produced. Each framework\u00a0begins with a thorough literature review, and in this foundational piece,\u00a0we gather and evaluate high-profile evidence and opinion on\u00a0the standard of care for the management of the complaint in question. We\u00a0seek out relevant textbook chapters, society guidelines, government health policies, review articles, and important\u00a0primary research publications, surveying\u00a0broadly within\u00a0medical fields that might be considered authorities on the topic at hand. A\u00a0complaint of “constipation,” for example, would trigger a search within at least the literature\u00a0of gastroenterology, family practice, internal medicine, and emergency medicine: all fields\u00a0that regularly encounter patients presenting with constipation.<\/p>\n

        The other sections of the framework then proceed from what is uncovered in the literature review. First, we generate a thorough list of differential diagnoses for the target complaint, focusing on pathologies that carry a high risk of morbidity or mortality. The patient is complaining of constipation, but are\u00a0they actually obstipated and suffering an obstruction? Or maybe they have a dangerous electrolyte dysregulation and resultant bowel hypomotility? Could it be hypothyroidism or maybe even malignancy? All conceivable etiologies are explicitly enumerated.<\/p>\n

        After assembling this list of differential diagnoses, we next\u00a0determine which data is\u00a0necessary to traverse the entries on the list:\u00a0which pieces of history, physical exam, and diagnostic testing are needed to exclude dangerous pathology and which are needed to arrive at the true, or at least at a working, diagnosis. We do this based on\u00a0the evidence and expert opinion found in the preceding literature review,\u00a0and the resultant set\u00a0of\u00a0data items includes history questions, physical exam maneuvers, laboratory tests, radiologic studies, and anything else that has been found to be\u00a0important\u00a0to a standard-of-care assessment.<\/p>\n

        3) Algorithm\u00a0creation<\/h2>\n

        When the framework document is complete, we begin to develop the actual algorithm that will power the Spruce Visit. We first take each facet of the history\u00a0that was found to be\u00a0important in the framework and convert it to a question in the algorithm, ordering the overall flow similarly to a typical medical interview and arranging it\u00a0into digestible sections for the patient (e.g., “Your Symptoms”). Behind the scenes, we also map the questions to recognizable groupings, such as “HPI” or “Social History,”\u00a0for\u00a0later display to the physician.<\/p>\n

        While we design the algorithm, we also focus on efficiency, so that an extremely thorough, best-practices history doesn’t feel like a never-ending interrogation\u00a0for the patient. We accomplish this in two primary ways:<\/p>\n

        \"visit_symptoms\"<\/p>\n

          \n
        1. Adaptive branching logic
          \nSome questions only need to be asked if other questions are answered a certain way. You wouldn’t ask a non-diabetic patient\u00a0what their blood glucose has been, and neither do we. The engine that runs our algorithms has support for complex boolean logic, and\u00a0we use it to ask the right questions of the right patients, sparing those who don’t need questioning\u00a0and saving time without sacrificing quality.<\/li>\n
        2. Question grouping
          \nSome questions, such as social history behaviors, can be asked as part of a list when they are in written form. In person, these questions can only\u00a0be asked one after another and answered one at a time, a tedious\u00a0process. In a Spruce Visit, the patient can review the related questions as a group, saving them a large number of clicks and extra screens to get through.<\/li>\n<\/ol>\n

          With the history complete, we then build the physical exam. Spruce Visits enable\u00a0patients to take\u00a0high-resolution photos and videos, and\u00a0we direct them step by step to\u00a0capture the parts of the physical exam that are relevant to their complaint or condition. It may not be intuitive to think that a useful physical exam could be obtained asynchronously, but we’ve put extensive thought into how it\u00a0works, and reliable patients can be very successful. Our recent article covering five ideal patients\u00a0for telemedicine<\/a>\u00a0shows\u00a0a few concrete examples of how you can make the physical exam of a Spruce Visit work for you and your patients.<\/p>\n

          \"One
          One of the physical exam questions in the “cough, cold, and flu” algorithm requesting a directed video.<\/figcaption><\/figure>\n

          Spruce Visit algorithms also include a number of features to keep you and your patients safe. Most importantly, each algorithm contains triage logic that watches for\u00a0patients with potentially dangerous presentations and guides\u00a0them quickly to appropriate care. Asynchronous telemedicine\u00a0is excellent\u00a0for many\u00a0situations, but recognizing and avoiding the rare emergencies that can occur is critical\u00a0to ensuring\u00a0that time-sensitive interventions\u00a0are not delayed. The triage functionality\u00a0in every Spruce Visit accomplishes this and makes\u00a0sure that you’ll never\u00a0open a completed visit to find\u00a0something that should have been seen hours before. Each algorithm also includes a system of embedded alerts that brings high-profile data to your attention at the top of every visit, helping you easily\u00a0recognize possible complicating factors and cases that might require\u00a0extra thought. With both the triage and alert systems\u00a0in place at all times, Spruce Visits are designed for safety above all else.<\/p>\n

          After initial drafting, the algorithm is then extensively reviewed. Each\u00a0algorithm is stored in a collaborative document, and\u00a0expert\u00a0physicians in relevant specialties assess them for\u00a0medical thoroughness\u00a0while experienced layperson copy editors provide suggestions to\u00a0maximize clarity and accessibility for\u00a0patients. One important thing to note is that Spruce Visit algorithms are built in a human-readable markup\u00a0language called “SAML”\u00a0that we developed\u00a0here at Spruce. With only\u00a0minimal instruction, anybody can follow the flow of a Spruce Visit in SAML, and this allows\u00a0us to share the algorithms directly\u00a0with our network of reviewers.\u00a0Here’s an example of a question written in SAML (left) with its resultant\u00a0display inside of a Spruce Visit (right):<\/p>\n

          <\/p>\n

          <\/div>\n

          4)\u00a0Ongoing feedback and maintenance<\/h2>\n

          After an\u00a0algorithm has been thoroughly vetted, we release it for use by physicians and other providers on the Spruce platform. We welcome feedback on our algorithms at all times, and they are under constant review and maintenance. As new evidence becomes available, the algorithms can be and are updated, ensuring\u00a0that your practice will always be at the forefront of current best practices.<\/p>\n

          \n

          We’re very proud of the technology that powers\u00a0Spruce Visits, of course,\u00a0but we’re equally proud of the rigorous development process and attention to detail that\u00a0underpins each one. We believe\u00a0strongly that modern\u00a0medical care requires\u00a0excellence in both technologic and human systems, and we work hard\u00a0to exemplify both of these\u00a0in every\u00a0Spruce Visit, every time.<\/p>\n","protected":false},"excerpt":{"rendered":"

          Part one of our series on Spruce Visits explored\u00a0what a Spruce Visit is and why we’re so excited about their power\u00a0to contribute to\u00a0efficient, high-quality medical care.\u00a0In case you need a quick refresher:\u00a0a Spruce Visit\u00a0is an\u00a0asynchronous\u00a0telemedicine encounter\u00a0that\u00a0uses an\u00a0evidence-based, condition-specific\u00a0algorithm to collect\u00a0a strong initial history and physical exam from a\u00a0patient and\u00a0provide it in an easily reviewable format to a\u00a0treating physician\u00a0or other care provider.<\/p>\n","protected":false},"author":1,"featured_media":449,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"slim_seo":{"title":"Spruce Visits: How Do We Build a Spruce Visit? - Spruce Blog","description":"Part one of our series on Spruce Visits explored\u00a0what a Spruce Visit is and why we're so excited about their power\u00a0to contribute to\u00a0efficient, high-quality medi"},"footnotes":""},"categories":[3],"tags":[7,8,5,4],"different-template":[],"class_list":["post-136","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-telemedicine","tag-caremessenger","tag-sprucevisits","tag-telehealth","tag-telemedicine"],"acf":[],"_links":{"self":[{"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/posts\/136","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/comments?post=136"}],"version-history":[{"count":0,"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/posts\/136\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/media\/449"}],"wp:attachment":[{"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/media?parent=136"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/categories?post=136"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/tags?post=136"},{"taxonomy":"different-template","embeddable":true,"href":"https:\/\/sprucehealth.com\/blog\/wp-json\/wp\/v2\/different-template?post=136"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}