Fall 2020 (Volume 30, Number 3)
Virtual Rheumatology Practice Resembles Bitcoin Mining:
By Philip A. Baer, MDCM, FRCPC, FACR
Rheumatology written fellowship examinations with
essay questions may be history post-pandemic but,
even if they survive, I doubt the title question is likely
to appear. If it does, feel free to use the information below.
In the tangible pre-COVID world, medicine was an outlier.
While electronic medical records (EMRs) had gained
ground, our digital transition lagged. Information transfer
was still dominated by the fax machine, interconnection
and interoperability of electronic health information was
rare, and our work with patients was primarily fee-for-service
piecework. Of course, the one-on-one interactions
with patients, including close physical presence and actual
physical examinations, are what we pride ourselves on
as rheumatologists, helping patients navigate the course
of their chronic diseases longitudinally.
Even then, in our financial dealings with payers, we had
moved to the digital world. Governments no longer accept
paper claims or even floppy disks; billing information is
transmitted electronically and paid in similar fashion directly
into our bank accounts monthly.
Now, practicing virtual medicine is the new normal.
While that could be on a video platform mimicking real-life
interactions, many of my visits are telephone-based. On a
daily basis, I am sitting at my computer in my home office,
with my EMR open, talking and pecking away at the keyboard
patient after patient, sending prescriptions and requisition
forms digitally to pharmacies, patients and health
care institutions. At the end of the day, my billing for all
that work is electronically sent to the Ministry of Health,
with payment virtually guaranteed: absent the in-person
interactions, I feel like I am creating money out of nowhere.
This virtual and digital work somehow lacks the weight and
substance of in-office interactions, even though the required
decision-making is as challenging, if not more so.
Being able to work without getting dressed or dressed up,
managing one’s appearance, and commuting to a workplace
setting influences that perception.
Of course, digital money is nothing new. Cash transactions
are steadily declining in popularity, as is the use of
cheques. We are in a period of an accelerating transition
to preauthorized payments, electronic fund transfers, Interac
e-transfers and digital wallets. While governments
and their central banks are said to be “printing money”
currently, they are not actually running a physical printing
press, as in the Netflix hit 'Money Heist.' The money funding
pandemic government programs like the Canada Emergency
Wage Subsidy (CEWS), Canada Emergency Business
Account (CEBA), Temporary Wage Subsidy (TWS), Canada
Emergency Response Benefit (CERB), and many others, is
all being created and transferred digitally.
Bitcoin miners also appear to create money out of nowhere,
by using computers to solve complex mathematical
equations. How is that possible? I learned a lot about bitcoin,
and the often-associated concept of blockchain, from
articles on www.investopedia.com. Apparently, the chance of a
computer solving one of these problems is currently about
1 in 13 trillion. I like my odds of correctly diagnosing an
unseen virtual patient from home a lot better. Meanwhile,
the “block reward” for solving these complex math problems
keeps falling, from 50 Bitcoins in 2009 down to 3.125
Bitcoins as of May 2020. Canadian rheumatologists can relate
to that, with fee freezes and rollbacks being common
in recent years. In Ontario, the Ministry of Health created
new fee codes for virtual billing at the start of the pandemic,
but then took the position that most virtual follow-up
visits should be paid at 33% less than in-person visits. That
dispute lasted months before being resolved in our favour
after intense lobbying.
Finally, mining for bitcoin requires massive amounts of
energy and sophisticated computing setups. All I require is
a phone, internet access, and a computer which can access
my EMR in the cloud. So, my virtual work is environmentally
friendly to the extreme, obviating commuting to the
office by myself, my staff, and my patients. Bitcoin mining
using pools of high-end computers requires electricity in
large quantities which, if generated from coal or oil, is environmentally
Bill Gates has been quoted as saying “Bitcoin is better
than currency in that you don’t have to be physically in the
same place.” With virtual rheumatology, you also don’t have
to be physically in the same place as your patient. Is it better
than the real thing? That question could turn up on a
future rheumatology exam, but you’ll have to work out the
answer on your own.
Philip A. Baer, MDCM, FRCPC, FACR