Being unwell on the free tier

By 2050 the doctor's note could be the last document a physician signs and the first that a subscription renews. Under a scheme being modelled by several national certification apps, how long a note would hold, and who could question it, would depend on the patient's plan. The fever would be the same on every tier.

Sick notes are increasingly issued digitally: in several countries short absences can be self-certified, and notes for longer illness are obtained through video or chat consultations with telehealth providers rather than in person. Subscription-based healthcare, in which a monthly membership buys faster appointments, app-based consultations and prescriptions, has grown alongside public systems. Consumer wearables now record skin temperature, heart rate and sleep, and some health apps and insurers already make use of that data. Employers commonly use absence-management software to log sick leave and flag patterns. Doctors in many systems report that administrative work, including certification, takes up a growing share of their time.

Version 31.4.2. Fixed: notes issued on the Free plan no longer show the word Provisional only in the employer view; it now appears in the patient view as well. Added: Basic and Plus subscribers may now be unwell on consecutive days. Removed: the box marked Other. These three lines, from the release notes of a mid-sized certification app, would describe the doctor's note of 2050 more precisely than any clinical guideline. Under the scheme, the note would no longer be a piece of paper a doctor hands over. It would be a document with a plan attached, and the plan would have terms.

The tiers would be arranged the way the industry arranges everything. A Free note would be valid for twenty-four hours, carry a grey watermark and allow the employer to request a second reading. Basic would extend this to three days, provided the temperature was logged by a compatible wrist device. Plus would offer seven days, a badge reading Accepted Without Query, and the doctor's signature rendered in a handwriting font of the subscriber's choosing. Premium would issue the note before the symptoms, on the strength of the device's forecast. A Premium subscriber could, in principle, be excused from Thursday on Tuesday.

Márta Fenyő, a warehouse coordinator on the Basic plan, would describe spending forty minutes in her car in the works car park because the app required the fever reading to be taken in natural light, to rule out a heated room. “The thermometer wanted to see the sky,” she would say. Her note would be approved at 14:10 and would expire at 14:10 the following day, fifty minutes before the end of her shift. The app would offer to bridge the gap for a small one-off charge. She would pay it, she would say, because the alternative was explaining a fever to a form.

Employers would subscribe from the other side. On the Enterprise tier, a human resources department could see each note's confidence score, the employee's plan, and the number of illness days remaining in the quarter. Some firms would offer to pay for staff Plus subscriptions as a benefit, on condition that the wrist device also be worn on rest days, so that the baseline was clean. A regional logistics company would go further and rank its depots by average note confidence. An employee's illness would become the one thing in the building that both parties paid a monthly fee to verify.

For doctors, the note would be the first part of medicine to scale. Under asynchronous certification, a general practitioner would no longer see the patient at all; she would see a temperature trace, a sleep graph and a checkbox, and approve them in batches on a Tuesday morning. Dr Ilona Szendrei, a practitioner in a market town, would describe signing two hundred and forty notes before lunch and then being asked by the app whether she wished to upgrade her signature to a premium stroke width. She would decline. The app would ask again the following Tuesday, in the same tone it used for the patients.

The regulator would describe the arrangement as proportionate. An official at the national certification authority would say that the tiers “reflect different verification needs, not different illnesses”, and that the Free tier would remain available indefinitely for people who are unwell only occasionally. Asked how occasionally, the authority would refer to its published guidance, which would define the threshold as fewer than four episodes per year, measured across a rolling window that the app would keep. Anyone ill more often than that would be advised, in a notification, to consider whether their needs had changed.

Bence Halmi, a bus mechanic, would let his Basic plan lapse on the third night of a flu because the card on file had expired. His note would be downgraded to Free at 00:01 and his employer notified at 06:00. He would go in at seven with a temperature of thirty-eight point four and a grey badge on his lanyard reading Provisional. “Nobody said anything,” he would say. “They just stood a bit further away.” At the end of the week the app would inform him that his plan had renewed, that his baseline had been restored, and that he was, according to the record, well.