This article is written by Adrian Rawlinson, MD and VP Medical Affairs, hims/hers

At hims and hers, our first priority is providing patients with access to the highest standard of care possible. We know sometimes it’s not easy to ask tough questions about your health, and going to the doctor’s offices isn’t always possible. That’s why as an MD, I’m thrilled to be part of what hims and hers is doing to bring telemedicine to more people around the country.

Telehealth has the potential to lower costs, increase access, and improve the health and wellness for millions of people around the country. That’s why hims and hers committed to building advanced telehealth platforms that address gaps around access and affordability in the healthcare market. These networks encourage people to make more informed decisions about their health, no matter what course of treatment they choose with their doctor.

hims and hers are a critical first touchpoint for people who have felt left out of the existing healthcare system, offering convenient access to an extensive physician network of over 140 doctors, informational resources via digital platforms, and a dialogue around typically taboo medical topics.

As part of our promise to provide access to comprehensive medical care for everyone, we want you to have a full understanding of how the hims and hers telehealth platforms work. This is the first of multiple installments showcasing what we do here at hims and hers and the power behind the telehealth platforms we use. Future articles in this series will address the inner workings of our company. Our goal is to help you better understand telehealth and provide insight into:

• Who are the doctors that practice on the hims and hers platforms and what are their qualifications?
• What is the nature of the physician credentialing process?
• Who are the hims/hers advisors and what is their role?
• The digital photo/ID check in process.

How It Works

Below outlines the online experience for someone seeking treatment. In this example the patient would be seeking treatment for erectile dysfunction

The patient would set up an account on forhims.com and choose the type of consultation appropriate for their medical condition. Each of these categories presents a tailored, online questionnaire tied to the specific health concern, and features the necessary technology  inherent to the hims and hers platforms. This ensures a comprehensive patient assessment for their licensed doctor to evaluate prior to creating a treatment plan. For a consultation related to erectile dysfunction, patients click the Shop Sex category.

If the customer is interested in erectile dysfunction treatment through the hims platform, then the related prescription - if deemed appropriate by a licensed physician - can be fulfilled through pharmacies who work with the platform or through a pharmacy of the customer’s choice outside of the platform. After selecting a product related to their specific erectile dysfunction condition, patients proceed to the checkout page. Payment includes:

• Cost of the drugs, which hims and hers pay to the pharmacies
• Costs for hims and hers managing pharmacy relationships and enabling customers’ online access to pharmacies' prescription fulfillment services
• Product membership fee, which is associated with a customer's overall use of and access to the platform

hims and hers also collect payment for the online consultation on behalf of the medical groups that employ or contract the physicians. These medical groups are referred to collectively as “Bailey Health,” but consist of a number of different professional entities. These consultation fees are paid to Bailey Health; hims does not retain any of the physician consultation fees.

Initial Questions

Once patients enter hims’ secure portal, they’ll share a detailed description of their medical concern. For erectile dysfunction in particular, they’ll include information around onset, duration, frequency and any previous treatments.  There are a total of eight questions in this section, determining any physical problems in the genital area such as:

• A marked curve or bend in the penis that interferes with sex, or Peyronie's Disease
• Pain with erections or with ejaculation
• A foreskin that is too tight
• Fibrous tissue in the penis (lumps and bumps under the skin that feels hard)
• Physical problems, scarring, or other issues related to your penis.

If a patient confirms one or more of these details, smart software will then guide them through an expanded workflow with five more specific questions to elicit information for the physician. Here, it’s important for the physician to know if the patient has been diagnosed with any of the following conditions:

• Priapism (erection lasting longer than 4 hours)
• Retinitis pigmentosa
• Anterior ischemic optic neuropathy (AION)
• Blood clotting disorder, abnormal bleeding or bruising, or coagulopathy
• Stomach or intestinal ulcer
• A prior heart attack, heart failure, or narrowing of the arteries
• Stroke or severe insufficiency of the autonomic nervous system
• Peripheral Vascular Disease
• Any history of QT prolongation in you, or even your family
• Sickle cell anemia, myeloma, leukemia
• Idiopathic hypertrophic subaortic stenosis
• Use of blood thinners
  
  

If a patient confirms one or more of these conditions, then their responses will be flagged  for the physician, and the questionnaire will proceed further with additional questions.

Risk Factors

Then we evaluate a patient’s risk factors, especially a comprehensive cardiovascular risk analysis, as erectile dysfunction can be the first sign of heart disease. Patients are asked a series of questions including the following:

• Do you have Diabetes?
• Do you have High Blood Pressure?
• Do you have High cholesterol?
• Did your father have a heart attack or heart disease at 55 years or younger?
• Did your mother have a heart attack or heart disease at 65 years or younger?

If a patient checks one or more of these items, then the system will prompt the patient to enter more specific details. For example: if the patient confirms diabetes, they will be prompted to answer questions about HbA1c levels, medications, diabetic complications (eye disease, vascular disease, kidney disease). Depending on the patient’s above risk factors, the doctor reviewing this assessment may require that the patient see their PCP instead.

Patients then receive an inquiry into possible relevant symptoms through a series of 11 questions. The questionnaire will automatically present follow-up questions related to each “yes” answer for the below:

• Do you have any chest pain or shortness of breath when climbing 2 flights of stairs or walks 4 blocks?
• Do you have any chest pain or shortness of breath with sexual activity?
• Have you experienced any unexplained fainting or dizziness?
• Do you experience any cramping of the legs with exercise?
• Have you had any abnormal heart beats or rhythms?

Drug-to-Drug Interaction

It is very important for physicians to know if patients are taking certain medications that may interact with erectile dysfunction medicines. Doctors using the platform perform a drug-to-drug interaction screen and list all medications contraindicated when using erectile dysfunction drugs. Patients must check their prescription medications, with emphasis on the below:

• Nitroglycerin spray, ointment, patches or tablets (Nitro-Dur, Nitrolingual, Nitrostat, Nitromist, Nitrolingual,
• Nitro-Bid, Transderm-Nitro, Nitro-Time, Deponit, Minitran, Nitrek, Nitrodisc, Nitrogard, Nitroglycn, Nitrol ointment, Nitrong, Nitro-Par)
• Isosorbide mononitrate, or isosorbide dinitrate (Isordil, Dilatrate, Sorbitrate, Imdur, Ismo, Monoket)
• Other medicines containing nitrates
• Alpha blockers to treat high blood pressure, prostate problems, PTSD, or nightmares: doxazosin (Cardura), prazosin (Minipress), terazosin (Hytrin)
• Aspirin
• Sildeanfil (Revatio)
• Riociguat (Adempas)

Patients taking any of the above medications will be denied a prescription for erectile dysfunction medication and referred to their primary care physician (PCP) for further evaluation.

Blood Pressure Measurement

It is mandatory for patients to share a blood pressure measurement (obtained via an at-home device, local pharmacy or PCP) when considering erectile dysfunction treatment.

Additional Considerations

We include a series of five questions about recreational drug use, including cocaine, rush, poppers, amyl nitrate and butyl nitrate. If the physician believes the patient is using any of these drugs, they will be denied erectile dysfunction treatment and referred to their PCP for further treatment. Physicians will also often suggest further interventions to help the patient (i.e. counselling, web references, referral to a drug abuse treatment program).

The evaluation will also screen the patient for any other medical diseases, surgeries and hospitalizations through a series of seven questions. Physicians pay close attention to:

• Surgery or radiation to the prostate or pelvis
• Kidney transplant or any condition affecting the kidney
• Liver disease
• Multiple sclerosis (MS) or similar disease, spinal injuries or paralysis, or neurological diseases
• Stomach, intestinal, or bowel ulcers
• Heart arrhythmias, which is an abnormal beating of the heart
• Any acquired, congenital, or developmental abnormalities of the heart including heart murmurs

If a patient confirms one or more of these symptoms, they will receive an additional series of questions to share more details.

Patients answer a series of six general medical questions that mimic an in-person doctor visit, such as:

• Do you have any other current medical problems?
• Do you take any other prescription medications?
• Do you take any over the counter supplements or medications?
• Do you have any medication allergies?
• Have you undergone any previous surgeries?
• Have you been diagnosed with any behavioral or mental health disorders?

The answers to these questions prompt more detailed questions to provide even more information for the physician. Patients always have the opportunity to provide as much insight as they can into additional medical history.

What Happens Next?

Hims’ electronic medical record (EMR) system compiles a medical chart with the patient’s information and routes it to a board certified physician licensed in the patient’s state. The chart flags findings of particular concern or importance for the physician, such as:

• Type II Diabetes Mellitus
• High blood pressure
• Daily dosage of Metformin and Lisinopril

After reviewing the chart, the physician will commence dialogue with the patient through a secure portal. We believe in shared decision making between physicians and patients; together, they will work together to select a treatment plan based on clinical evidence, balancing risks and expected outcomes with patient preferences and values.

If the treating physician decides that prescribing a medication is the right treatment plan, then they will provide the patient details of the proposed treatment plan and  ensure that the patient doesn’t have any questions or concerns. If a patient accepts this treatment and indicates they do not have any questions or concerns, then the physician provides a prescription for the medication. The patient is encouraged to read the treatment  plan carefully prior to starting the medication. Some specific sections in the treatment plan include:

• When to take the medication
• Advice on dosing
• Possible side effects
• How to store the medicine
• Possible drug interactions
• options if medication is ineffective
• common alternative treatments
• advice as regards ongoing communication with PCP
• contraindications and precautions

It is important to note that a significant number of patients are denied access to medication on the hims platform due to drug interactions, medical conditions, allergies, substance abuse, etc. If patients are denied treatment, a physician will provide a detailed summary of their visit and refer the patient back to their PCP.

Physicians using the hims and hers platform are also trained in providing lifestyle counseling. For patients with erectile dysfunction, this includes discussing and providing information about:

• Smoking and/or substance abuse (including alcohol)
• Reducing fat and cholesterol in diet
• Exercise
• Improving compliance with cardiovascular and diabetes medications
• Reducing stress
• Increasing optimism about the potential resolution of erectile dysfunction

Follow Up

If a treatment plan offered through the platform is decided as the best course of action, the patient has ongoing access to the physician to address effectiveness, possible side effects, or any other questions or concerns that the patient may have. This can enable faster and more effective access to a physician than a patient would typically receive after seeing a doctor in person, and enhance the likelihood of a successful therapeutic outcome.  

In Conclusion

The physician consultation process conducted through the platform creates an extremely detailed “medical fingerprint” for each patient through a dynamic and intelligent system, designed to gather critical patient information that doctors need to provide medical advice. The system used by the hims and hers platforms is designed to create a unique screening  for each patient to ensure a best possible treatment plan for each individual.

When it comes to the patient consultation process, I frequently consider Dr. Atul Gawande’s The Checklist Manifesto, which makes a distinction between errors of ignorance - mistakes that are made when people don’t know enough - and errors of ineptitude - mistakes made when people don’t properly use what they know. Errors of ineptitude can occur in a brick & mortar doctor’s office; even the most competent doctor can miss a step, forget to ask a key question or, in the stress and pressure of the moment, fail to plan properly for all scenarios. The hims and hers intelligent workflows ensure we address each pertinent aspect of care, and specific data points generated through the platform can create more consistencies than an in-person doctor’s visit.

As a licensed doctor, I would not recommend the hims and hers platforms if I didn’t believe we were providing a high quality patient experience.  But because of these advances in technology, attention to detail for the patients allows doctors like me to provide care to more patients who are looking to improve their health and wellness.