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Amazon’s health ambitions sometimes clashed with medical best practices, nurses say

[washingtonpost.com]1 month ago

Fielding calls one day in 2019, a nurse for Amazon Care, the company’s then-new telehealth service for employees, found herself on the phone with a patient talking about suicide.

With dawning horror, the nurse realized she had no way to transfer the caller directly to someone who could help. Instead, she had to tell them to call another number. And then she had to hang up — in violation of standard protocol not to abandon a patient in crisis.

“We didn’t even have an ability to locate where they were calling from. We didn’t know where they were. That was a huge concern from the clinical side,” said the telehealth nurse, who like others spoke on the condition of anonymity because she signed a nondisclosure agreement.

The patient survived, the telehealth nurse said, but she complained to Amazon engineers about the “massive safety issue.” Nearly a year later, the company finally made it possible for nurses to directly transfer callers. By then, the telehealth nurse was on her way out.

“I wanted to feel like I was meaningful as a nurse," she said. “Not a cog in the Amazon machine.”

Created as a primary- and urgent-care alternative for employees in Seattle, Amazon Care has since expanded rapidly, with telehealth services available in all 50 states and in-person services in at least seven cities, including Dallas, D.C. and Baltimore. It also has signed up a half-dozen other companies, including Hilton and Amazon-owned Whole Foods Market, becoming a major piece of Amazon’s aggressive ambitions for health care.

CEO Andy Jassy has made health care a priority, naming Amazon Care as an example of “iterative innovation” in his first letter to shareholders earlier this year. In July, Amazon announced plans to acquire concierge health-care start-up One Medical, signaling its growing interest in becoming a consumer health-care brand. And this month, Amazon Care announced that it would begin offering virtual mental health services through a partnership with on-demand therapy company Ginger.

Patients who have used Amazon Care largely have loved the convenience, reviews, ratings and interviews with employees suggest. “They could see when I was on my way, just like your package,” said a second former Amazon Care nurse who worked on the mobile team.

Amazon is “really good at making it really easy for you,” said Tom Andriola, chief digital officer at UC Irvine Health, where he’s worked with Amazon on various initiatives. “Most people’s experience with health care is anything but that.”

But some health professionals who worked for the service said Amazon sometimes prioritized pleasing patients over providing the best standard of care. Six former employees and managers said the company’s efforts to rapidly build Amazon Care led to clashes with some medical staffers, who felt the company sometimes ignored their concerns about its approach to health care. All six spoke on the condition of anonymity, either because they are subject to nondisclosure agreements or because they still do business with Amazon.

Amazon has come to dominate industries from logistics to cloud computing to entertainment by being fast, frugal and obsessed with delighting customers. The early tensions within Amazon Care underscore the challenges inherent in bringing the Amazon mentality to medicine.

Paddy Padmanabhan, a health-care consultant, said it’s normal for opinions to differ between the tech and medical sides of a health-care start-up, but Amazon may have underestimated some of those challenges.

“Fast forward, and they realized those kinds of services require degrees of staffing and scaling that’s not easy in the health-care world,” Padmanabhan said.

Amazon says it has prioritized patient and employee safety in building Amazon Care, and that it values the opinions of its clinical staff, whose input it uses to improve the service. For example, Amazon Care clinicians, who “have always had a process to escalate emergencies,” can now transfer calls internally, spokesperson Christina Smith said in a statement.

“Across Amazon, we strive for constant innovation on behalf of our customers. As a result, Amazon Care has evolved and improved for both patients and clinicians since the days of our pilot program,” Smith said. (Amazon founder Jeff Bezos owns The Washington Post.)

As the company embarks on what promises to be a major expansion into health-care delivery, Amazon is “going to try and do what they do in every other line of business: They’re going to try and make it better than everyone else, make it less expensive and get crazy adoption because of convenience,” said one former Amazon Care executive.

“But,” the executive added, “health-care is different. It’s hard.”

Fast and frugal

Medical professionals who came to work at Amazon Care were often excited about the potential to leverage technology to improve patients’ experience, according to the former employees. But the reality of working at Amazon sometimes came as a shock.

While planning to expand Amazon Care beyond Seattle, Amazon managers wanted to avoid building a physical hub. Instead, they asked if nurses could store and dispose of medical supplies at home and stabilize patient blood samples using centrifuges in their personal cars, the two former nurses said. They said the staffers protested the ask.

Amazon, which did not ultimately build physical hubs for Amazon Care, said it could not find records of these complaints and that mobile nurses are provided with equipment to dispose of supplies.

Like other tech companies, Amazon has had designs on health care for years. It acquired prescription delivery company PillPack in 2018, relaunching it in 2020 as Amazon Pharmacy, which offers online prescription ordering and delivery. And Amazon Web Services, the cloud computing division Jassy ran before taking over as CEO a year ago, has worked to make inroads into the industry, launching a health-care vertical in 2021.

Amazon also embarked on an ill-fated health-insurance venture with finance giants Berkshire Hathaway and JPMorgan Chase called Haven that ultimately disbanded last year.

And just last month, it acquired One Medical, a concierge primary-care start-up based in San Francisco.

Just as Amazon’s 2017 purchase of Whole Foods fueled its grocery ambitions by providing access to physical stores, labor, supply chain infrastructure and shopping data, its acquisition of One Medical brings with it brick-and-mortar clinics, a staff of medical practitioners and health data.

Whether it merges the company with Amazon Care or leaves it as a stand-alone, One Medical could help Amazon jump-start its aspiration to be the brand patients turn to when they’re sick and in need of quick, convenient care.

After graduating from Amazon’s secretive internal Grand Challenge incubator, which is supposed to spin ideas for new businesses into marketable products, Amazon Care launched publicly as a health benefit for Seattle-based Amazon employees in September 2019. The goal was to build a health-care service that eventually would be available to all employees of Amazon, the second-largest U.S. private employer.

Initially, Amazon Care clinicians saw patients on-site, at home and virtually, the former employees said. After the coronavirus pandemic began, visits included porches, garages and backyards, the former mobile nurse said. It became a popular option for Amazon employees seeking coronavirus tests and, later, vaccines.

The clinicians who treat Amazon Care patients work for a company called Care Medical. According to Amazon, Care Medical is an independent company and not an Amazon subsidiary. Amazon uses this structure, which is typical in health care, both to protect patient data and because most states have regulations that prevent it from employing physicians “engaged in the practice of medicine,” Smith, the spokesperson, said.

Smith said Amazon sees itself as an “operational and technology service provider to Care Medical,” which was originally called Oasis Medical Group and was founded by an Amazon employee in Washington state in 2018.

But in practice, the two former nurses and the former executive said Amazon called the shots and Care Medical existed to execute the company’s vision. And as that vision expanded, some Care Medical staffers worried that Amazon was moving ahead without implementing the safeguards typical of a medical organization.

The former Amazon Care executive compared it to “seeing patients in a clinic before the bricks have been put around the walls,” adding: “That’s not something everybody is comfortable with.”

For example, Amazon Care didn’t collect emergency contact information for patients until the clinical staff told them it was necessary. And while Amazon generally prefers to build its own software, in some cases it had to buy out-of-the-box tools from third-party vendors. The former employees said Care Medical staff chafed at Amazon’s decision not to wait for a widely used medical software company to build a custom electronic health record management tool, opting instead to go with what one called a “bargain basement program.” The thrifty move made delivering quality care more difficult, the two former nurses said.

Meanwhile, the high tech tools Amazon did supply — such as wireless stethoscopes that nurses in the field were supposed to use to transmit live patient audio to doctors — didn’t always work, the two former nurses said. Amazon Care wanted to have the agility of a start-up, but the company was sometimes overambitious about the scope and speed of the operation, three former employees said.

Smith said clinicians have regular stethoscopes as well as the wireless ones. Amazon “follows all applicable requirements related to patient healthcare records,” Smith said.

In spring 2021, Amazon Care launched its first mobile, in-home services outside Seattle, starting with D.C. and Baltimore. Around the same time, it announced its first corporate client, exercise bike manufacturing company Precor, which then had 800 employees nationally. By September 2021, around 40,000 people were enrolled in Amazon Care, according to Business Insider.

By February 2022, Amazon said virtual care was available nationwide and that in-person treatment would be available in more than 20 cities by the end of the year. Today, Amazon Care has a half-dozen corporate customers, including TrueBlue, Hilton and Silicon Labs, as well as Whole Foods. Like Amazon, these employers offer Amazon Care as a benefit that has the added perk of keeping overall health-care costs down.

To provide care nationwide, Amazon Care asked the Seattle-based clinical staff to get licensed in multiple states. But the former nurses and executive said there were challenges to treating patients remotely.

Building new tech products while grappling with changing regulations in multiple locations iscomplicated, said the former Amazon Care executive. “Who can deliver the care? What services can you do over telehealth? Can it all be virtual? All of that makes it really hard,” she said.

The former telehealth nurse, who was based in Seattle, recalled talking to a patient in Missouri who described symptoms of a sprained ankle. To diagnose a sprain, the patient would need an X-ray. But because the nurse neither lived nor worked in Missouri, she wasn’t able to recommend an urgent-care facility with an X-ray machine.

“You’re trying to take care of somebody and you don’t have a resource,” said the nurse. “What service am I actually providing if I don’t even know where you should go?”

Some clinicians ended up practicing in so many places, she said, that they had trouble keeping track of various state regulations. In the midst of treating patients, they sometimes sent messages to support staff asking whether they were allowed to provide certain services, such as prescribing antibiotics. But they didn’t always get a clear answer.

Even with the nurses working multiple states, Care Medical couldn’t meet Amazon Care’s staffing needs. So, as it has with its warehouses and delivery operations, Amazon turned to third-party contractors to fill the gap, four of the former employees said, hiring traveling nurses from staffing agencies on temporary contracts.

The use of contracted nurses is relatively common for virtual health companies, but nurses who had joined Amazon Care in hopes of building a better-than-average service were disappointed. Because their contracts were so short and operations at Amazon Care changed so frequently, it was hard to maintain standards and keep track of who was doing a good job, according to the telehealth nurse. “They were essentially gig workers, and their training was really subpar,” she said.

“Health care is a human-capital-intensive business,” said Padmanabhan, the health-care consultant, “and there’s a scarcity of workers.”

The ongoing national nurse shortage has inhibited Amazon’s plans for Amazon Care, he said, and ventures like buying One Medical provide Amazon access to a new labor pool.

Amazon’s Smith said Amazon Care has a “care coordination team and dedicated licensing team that keeps track of local regulations and supports clinicians providing care across states,” which is “common practice for providers who work in telehealth settings.” She said resources made available to Amazon Care clinicians are “updated frequently and on a regular basis.”

Hiring contractors to provide care is also “standard practice in the industry,” said Smith, and was always part of Amazon’svision for building Amazon Care. She said Amazon’s patient satisfaction scores for care provided by contractors is the same as for employees, and that “third-party nurses are required to participate in the same comprehensive training as Care Medical clinicians.”

But as reliance on contractors grew, the former telehealth nursesaid, “I felt less confident in the care I was part of delivering.”

Customer obsession

Clinical staff may have been frustrated with Amazon Care, but the appeal for patients was clear. With Amazon Care in-person services, they could find out in 15 minutes if they had strep throat or a urinary tract infection — and get a prescription delivered to their door less than two hours later. Wary of doctors’ offices during the pandemic, parents could get care for their kids without leaving the house.

Laporsha Ford tried Amazon Care after finishing a night shift early one Saturday at an Amazon warehouse near Houston.

“By the end of the night, I had a lump in my eye that was very painful,” she told The Post. “As soon as I got off work I downloaded the app,” she said, “and was able to get a doctor and a prescription for some eye drops within an hour.”

If Amazon’s attempt to disrupt health care by putting customers first ruffled feathers sometimes, that was just part of the company’s innovative culture, an early Amazon Care manager said. “Some people are going to get it, and some people aren’t.”

Amazon’s obsession with customers did raise some concerns within Amazon Care. In news releases about Amazon Care, Amazon boasts of having “a satisfaction rating of 4.7 out of 5.” But the former Amazon Care executive said there’s a “tension between what would give you good ratings versus what is sound clinical care.”

The former nurses and executive who worked on Amazon Care said Care Medical bosses lacked the power to push back against some of Amazon’s decisions. “It comes down to who has leverage in the relationship,” said Andriola, from UC Irvine Health.

Amazon Care was under pressure to hit certain goals for growth and customer satisfaction, and Care Medical ultimately “didn’t have as much autonomy as they hoped or wanted,” according to the former Amazon Care executive. “Where in traditional health care clinicians run the shop and guide everything else, this was more the reverse.”

That cultural divide between Amazon Care and Care Medical was deepened by patient privacy rules that prevented Amazon employees from observing Care Medical staff doing paperwork or riding along with mobile nurses on their visits with patients, the two former nurses said. As Amazon sought to improve efficiency, the nurses said they constantly fielded questions about why they were taking so long.

The former telehealth nurse remembered an Amazon staffer telling her, “You know, a lot of people here consider you the warehouse workers of Amazon Care.”

As home health-care workers, mobile nurses are at higher risk for workplace violence, but twoformer nurses said they felt Amazon sometimes didn’t take their safety seriously. The former mobile nurse said her car was broken into while she was working; other nurses were asked to see patients in hotel rooms and had to travel through street protests to appointments, the nurses said.

Smith said Amazon Care clinicians “are trained and empowered to refuse to enter any space they feel is unsafe, to leave a space if it begins to feel unsafe, and to leave all equipment behind and prioritize only their own safety” and that it has “never had a reported safety incident in any Care visit.”

But when Care Medical staff requested that Amazon buy a tracking app with an alert function, the former mobile nurse said, Amazon declined, opting to use an in-house tool that didn’t have an emergency button feature.

“We had a couple of our nurses move from mobile to virtual because it was crazy out there,” the former telehealth nurse said. “They said, ‘This is insane, this isn’t safe, and I’m not doing this anymore.’ ”

The misalignment between what Amazon wanted to build and how medical staffers thought it should be built was ultimately too much for the former mobile nurse, who quit because of the lack of support.

Although Amazon claims Care Medical is an independent organization, “it’s fully run by Amazon Care in the Amazon way,” she said.

But, the nurse said: “We’re not a package, we’re a person. And that’s different.”

https://www.washingtonpost.com/technology/2022/08/19/amazon-care-patient-safety-concerns/

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