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Our Take: Another Arrow in the Quill of Disruption-Amazon Pharmacy to Make its Mark Our Take: On November 17th, Amazon announced the launch of Amazon Pharmacy in the U.S (technically Amazon Pharmacy and Amazon Prime prescription savings benefit-PrimeRx). This new service allows customers to purchase prescriptions through the Amazon app using most forms of insurance as well as 24/7 access to consultations with pharmacists. With PrimeRx. Prime members can purchase branded and generic prescriptions at discounted rates on the app or at 50K pharmacies across the U.S with free two-day delivery or in-store pickup and automatic enrollment included in the program. While the addition of a broader pharmacy offering takes Amazon more deeply into the prescription drug business, over time we expect this expansion will succeed and position the company well to disrupt already existing pharmacy giants. Given its strong existing customer base, deep reserve of existing financial and distribution resources, and low prices combined with customers increasing reliance on online shopping platforms during COVID, we expect Amazon to broadly disrupt the market for retail pharmaceutical sales. Description: Amazon began entering the pharmaceutical market with its acquisition of PillPack in 2018, and appears poised to apply lessons learned from that acquisition to deepen penetration into the pharmaceutical market. Amazon pharmacy will offer 80% off generic medications and 40% off brand scripts for prime members, providing better deals than purchases made at brick mortar competitors. The company also provides transparency, showing the cost difference between paying for medications out of pocket or using health insurance. The service will feature a two-day delivery option for Prime members as well as easy to navigate platforms and pharmacists to answer questions related to medications. Customers can also use other Amazon devices such as Alexa as another means of purchasing medications and for medication related reminders. As a result of these features fulfilled through Amazon’s partnership with Inside RX (a subsidiary of CI’s Evernorth), other retail giants already in the pharmaceutical market are looking to add features such as delivery tracking, price transparency, and lower prices to remain competitive in the market. Large retailers, such as Walmart, who are already engaged in the pharmacy business are also expected to increase physical presence and add pharmacy delivery in an attempt to compete with Amazon’s latest additions. This expansion puts Amazon in more direct competition with pharmacy giants CVS Health Corp. and Walgreens Boots Alliance Inc.as well as with newer online pharmacies such as GoodRx. Implications: Given Amazon’s deep bench of distribution expertise along with Amazon’s user friendly and familiar online interface, we see high likelihood of successfully disrupting the market. As the COVID pandemic continues to cast a shadow on in-person retail, online first will continue to take share as the default choice whenever possible, further allowing Amazon to deepen ties with U.S. Prime members, now numbering over 100 million. We also see this as a threat to other online pharmacy offerings like GoodRx given the relative size difference in subscriber bases of well over 10x, but do not believe it to be the primary target (more in a later post). The extension of online pharmacy, where medications can be purchased from the comfort of your own home at competitive or more steeply discounted prices and arrive within two days. This will be particularly important during this next wave of COVID and position Amazon as the default option for prescriptions over the next 9-12, months allowing it to solidify the change in consumer behavior.In addition, the prospect of steadily increasing case counts and additional COVID restrictions will likely further limit office/facilities-based work and trips outside the home, undercutting one of the brick and mortar store’s main competitive advantages; proximity and ability to serve urgent needs. For example, Amazon could integrate Whole Foods to help supply those who require prescriptions for emergent needs by supplanting it's free one hour grocery pickup, (launched in October), which has been very popular with new customers who account for over ⅓ of curbside orders. Of course, as Amazon always does, we expect them to continually iterate, gather data and develop new options which will further enhance their chance of success. The Other Shoe Drops: Amazon Pharmacy is Here Race and Health A lack of Data on Race Hampers Efforts to Tackle Inequalities Event: The most recent issue of The Economist published an article on “Race and Health” noting that the lack of solid data and data collection hampers efforts to address inequalities. The article notes that “COVID-19 has laid bare countries broad racial inequities in health and exacerbated them… [and] also highlighted the scarcity of decent data on ethnicity and race.” In addition, it noted that much like the debate on gender equality there is “too much intuitive argument and too little data”, however, unlike gender, many remain uneasy about asking for and collecting information on ethnicity and race. Description: During the initial months of the pandemic in New York, black and Hispanic children were 2 times more likely to lose a parent/caregiver to COVID than those who were white or Asian. In England a black man is nearly 4 times more likely to die from the disease than a man of similar age. During the peak of the pandemic, due to scarcity of data, only 7% of reports about COVID deaths recorded data on ethnicity. While it is understandable that many groups such as Jews and Roma or Romani of Europe are opposed to registering race or ethnicity since they have seen how it can be used detrimentally against them, this would argue for using data privacy and security to de identify data rather than not collecting it. For example, after Brazil began collecting data in the late 1990s broken down by five different skin colors the gulf in infant mortality between indigenous and white babies became apparent, simultaneously demonstrating the need for a move away from catch all terms (such as BAME in Britain-Black, Asian, Minority or Ethnic).. Implications: The COVID pandemic has highlighted the need for better collection and analysis of more granular data on race and ethnicity to address inequities as well as the potential role for digital tools to help fill this gap. As the Brazilian example demonstrates, the only way to tackle the inequalities and injustices is by bringing up statistical visibility and ensuring that data has the right degrees of granularity. In addition, researchers need to highlight that race itself is not the cause of disparities but rather a reflection of policy failures such as access to education, healthcare and employment. A Lack of Data on Race Hampers Efforts to Tackle Inequalities Telehealth Impact During COVID-19 Event: On November 17th, the COVID-19 Healthcare Coalition published the Telehealth Impact Physician Survey, which captured the opinions of 1,594 physicians and other qualified healthcare professionals. More than 75% of respondents said telehealth enabled them to provide quality care; however, barriers and challenges still exist and are anticipated beyond the COVID pandemic. Description: The survey has allowed telehealth to prove its value as a safe, effective, and necessary care delivery option that can provide quality care to patients when and where they need it. The survey findings also show strong support for telehealth from physicians and qualified healthcare professionals. Of those surveyed, 60% reported telehealth has improved the health of their patients, 68% report they’re motivated to increase telehealth use in their practices, 55% indicated that telehealth has improved the satisfaction of their work, and 80% indicated that telehealth improved the timeliness of care for their patients who are also in favor of using telehealth for care. The survey also found that about 73% of respondents indicated that no or low reimbursement would be a major challenge post-COVID, and more than 64% said technology challenges exist for patients, serving as a barrier to the sustainable use of telehealth. Barriers and challenges have to be addressed because telehealth services are anticipated to be highly used even after the pandemic. Implications: Telehealth and remote care services have proven critical to the management of COVID and the future of healthcare, especially since it’s here to stay. Future telehealth policies should be data-driven and seek to address the challenges for patients and providers alike. Telehealth has helped address several issues such as provider shortages and the growing gap of access to care in the most vulnerable populations. There should be further exploration to ensure high-quality delivery of telehealth and sustainability over time. Government officials, physicians, and other stakeholders need to work together to address challenges that remain for patients, including lack of access to technology, internet, low broadband connection, and low digital literacy. Telehealth Impact During COVID-19 Financial Problems aren't the Only Reason that Patients don't Pay their Medical Bills on Time Event: Health Leaders Media reported that a recent survey by Waystar found a number of varied reasons why patients don't pay their medical bills on time, with financial problems being only one among many. The study found that while 48% of those surveyed had been late on a medical bill, only 43% said they fully understood their bill and 56% had received a surprise medical bill. Overall the study noted that patients are confused, unaware, or misinformed of their medical bill information, all of which contribute to keeping them from paying on time. Description: Waystar surveyed 1,000 consumers who have received a medical bill from a hospital or specialty provider for medical treatment within the last six months. They found that financial difficulties were cited by only 51% of those surveyed. However, over a third (37%) assumed their insurance would pay it, while 20% were unclear about how much they owed while another 20% assumed their bill was incorrect. The article went on to note that sometimes “the bills themselves stood in the way of people paying” with only 57% of those surveyed not fully understanding their most recent medical bill. In addition, although 46% of consumers state that their provider proactively gave them an upfront cost estimate for healthcare services, they also stated that those estimates were often inaccurate. Implications: Medical bills are easily misconstrued by patients due to misconceptions, lack of clarity, lack of communication, and erroneous out-of-pocket estimates. In looking to improve billing and collections payers and providers should look to simplicity and clearer language as much as financial assistance. In addition, there needs to be a clearer end-to-end process for patients to understand and pay their medical bills. This could include clarifying the payment procedure with the patient, setting up an automatic payment system, advising patients of the out-of-pocket costs sooner, or setting up push notifications to the patients to pay on time. More work is needed to make this a user-friendly and seamless process for patients. Financial Problems aren't the Only Reason that Patients don't Pay their Medical Bills on Time Digital Mental Health on the Rise, but Engagement, Access, and Trust Continue to be Barriers Event: On November 17th, an article in Mobihealthnews noted that although digital mental health has raised significant amounts of capital and gained much broader adoption, it is still hampered by a lack of clear efficacy standards, poor engagement and user trust issues. The article which reviews a new report from WISH entitled, the Digital Mental Health Revolution: Transforming Care Through Innovation and Scale-noted that despite the fact that about one in five people are affected by mental health issues and an estimated one in twenty disabled by mental health issues, getting people into care remains a barrier. Description: Since the beginning of the pandemic, 75% of some populations are experiencing psychological distress, and many are developing mental illness for the first time. In order to combat this and other existing mental health issues, providers and payers have turned to digital therapies to help expand care. Nevertheless a gap remains between what people need and what existing systems can deliver. The WISH report identifies 4 key attributes that should be central to decisions by health systems, developers, investors, and users on what to buy and build in the future: 1) moving apps to an integrated operating system of care, 2) developing tools that are highly effective and engaging, 3) addressing inequalities, and 4) building trust in digital tools. Revolutionizing in those areas will accelerate progress, close the gap, and overcome barriers that include access, relevance, privacy, and security. In addition, the report points out that despite the explosion of mental health tools, with over 10,000 mental health apps currently available, many of these tools have underperformed, leaving a gap in “effective coverage” for mental health disorders. Implications: While the COVID pandemic has helped advance the technology and digital tools available to address the ongoing mental health crisis, with digital tools at the forefront, as few as 10% benefit from traditional mental health services, even in well resourced countries. Policy makers need to distinguish between heavily researched tools which face low rates of consumer adoption and commercially driven innovations, which have less research to support effectiveness, but see higher engagement rates. Among other things the report suggests focusing on tools that have proven effectiveness, low cost and engagement with large volumes of patients worldwide such as : instant crisis text messaging, digitized or gamified versions of cognitive behavioral therapy (CBT) and online training for patient facing staff. In addition the report highlighted the need to include “all nationalities, ethnicities, ages, and [those with] specific disabilities in addressing mental health issues. Digital Mental Health on the Rise, but Engagement, Access, and Trust Continue to be Barriers K Health raises $42 Million to Expand its AI-powered Telemedicine Platform Event: Venture Beat released an article that K Health, a startup with a software platform that digitally connects patients to doctors has raised $42 million to expand its AI-powered telemedicine platform, bringing its total amount raised to $139.3 million. According to the article, K Health’s platform takes into account medical histories, the clinical outcomes of millions of people, and the experience of thousands of doctors to deliver treatment information on hundreds of diseases. K Health's smartphone app, “K”, boasts more than 4M members and, according to the company is growing 10K-15K members per month. Description: K facilitates in-app visits from doctors that K users can speak to for a $19 one-time fee or for $9 per month. No insurance is required. The doctors review an AI-assisted breakdown of the patient’s symptoms and then diagnose, prescribe, or refer the patient as appropriate. K Health users can also text message doctors at any time. Mental health services are offered, and prescribed medication can be delivered to users for $34 per month. Additionally, K Health rolls out test maps that shows where people are reporting COVID symptoms and a nationwide map that shows all COVID testing centers. The company announced it will collaborate with the Mayo Clinic to integrate the health system’s Clinic Data Analytics Platform to support Mayo patients and doctors. Since the onset of the COVID pandemic, more than one million new people have turned to K Health for their primary care and mental health needs. K Health has grown 1,000% just this year alone. Implications: According to a study published by the U.S. Centers for Disease Control and Prevention (CDC) millions of patients wait at least two hours to see a health care provider. As the pandemic is continuing, the market for chat-based healthcare solutions is growing. Tech giants like IBM, Facebook, and Microsoft have partnered with governments and private industry to roll out chatbot-based solutions in response, as have a number of startups. In addition, the pandemic has accelerated the move to remote and virtual care. Even before the pandemic, 9 out of 10 seniors said they’d prefer to stay in their homes over the next 10 years, highlighting the need for these types of solutions. In addition, K Health can help bridge the gap for those without health insurance or in underserved communities, with prices starting at $9 per month to chat with a doctor or $19 for a one-time session and mental health services for $34 per month. K Health Raises $42 Million to Expand its AI-Powered Telemedicine Platform

Yes, Evidence Does Support Telemedicine “Our Take”: The COVID-19 pandemic has transformed how care is delivered as areas affected by the pandemic have to adopt social distancing practices to stop transmission of the deadly disease. While the crisis has presented the U.S. healthcare delivery system with unprecedented challenges, telehealth's rapid adoption has allowed healthcare delivery to adapt its model almost instantaneously. Telemedicine serves as an innovative and effective approach in providing secure, safe, and real-time help to patients in need while improving their health outcomes. Telehealth can be a replacement for in-person visits in cases where it has been shown to be comparable or better relative to in-person appointments. In addition, as regulatory restrictions were lifted out of necessity, providers found themselves able to provide essential services to patients with limited access to healthcare services in under resourced communities. Despite the many benefits telehealth has brought to society, many barriers remain that have adverse effects on greater efficiency of telemedicine appointments. Description: Telehealth brings enormous value to managing population health interventions since it has lower overhead than facility based services, can broaden geographic reach, and can extend service offerings to areas that may not be able to support certain specialties on their own. During the public health emergency (PHE) the delivery of telehealth services was eased by the rapid legislative and regulatory changes to payment and privacy requirements, particularly the temporary waivers of certain delivery restrictions and new coverage by CMS, which have broadened access and facilitated payment for more services. For example, according to a survey conducted by the COVID-19 Healthcare Coalition, telehealth and remote care services have proven critical to managing the pandemic while ensuring uninterrupted care for 100 million Americans with chronic conditions. In addition, according to the U.S. Dept of Health and Human Services, telehealth and related technologies are transforming the way care is delivered to underserved populations who face burdensome travel times as well as those balancing the multiple demands of family, work, and other activities where telehealth can facilitate continuity of care. Telehealth has addressed a number of concerns that will remain after the pandemic, including a severe provider shortage and the growing gap in access to care for rural communities and vulnerable populations. Moreover, as we have seen, the increased availability of telehealth services has reduced disease exposure for staff members and patients, preserved personal protective equipment, and minimized the patient surge in facilities. Implications: The evidence from the rapid increase in deployment of telehealth services during the pandemic has demonstrated that telehealth services are an effective adjunct and sometime substitute for in-person care, are particularly good in certain service lines, and will be an efficient component of care delivery in the years ahead. Moving forward a challenge will be sustaining the regulatory relief achieved during the pandemic, integrating virtual care into workflows and striking the optimal balance between in-person visits and virtual care. In terms of service lines, a 2018 article in Health Affairs entitled “The Current State of Telehealth Evidence: A Rapid Review” as well as a number of other peer reviewed articles have found telehealth services to be comparable or better relative to in-person appointments in behavioral health, cardiovascular disease, diabetes, and even physical rehabilitation. In addition, a June 2020 study published in Gastroenterology found that 67% of Penn Medicine gastroenterology and hepatology patients surveyed found their video and telehealth appointments as “positive and acceptable substitutes to in-person appointments, while 80% of their clinicians surveyed “were ‘somewhat/very satisfied’ with the medical care they were able to provide their patients”. Telehealth can fill an essential and longstanding need in our health system, but complications remain to make telehealth a viable option for patients and providers. Caregivers must also take into account constraints on broadband availability and accessibility limitations for seniors as well as the physically challenged. Operational obstacles include measuring and improving return on investment, expanding telehealth services, true integration of virtual care into care models and sustainability. In regard to ROI, as we have noted earlier, stakeholders and providers need to think about indirect and intangible costs which are more difficult to incorporate into current business models, but which which should be measured For example, data has shown that patient satisfaction and engagement is improved via telehealth, as they are saving fuel, time, and money by employing telehealth services. There has also been a reduction in missed appointments, which adversely impact patient health and the economics of physician practice operations. In February 2020, Ohio State Wexner Medical Center found missed appointments decreased markedly with the implementation of telehealth with overall missed appointments down over 35% and a decline of almost 24% in missed appointments for Medicaid patients. To keep up with the momentum, telehealth should deliver care that is respectful and responsive to individual patients’ preferences, needs, and values by ordering timely, efficient, and equitable access. A recent Brooking Institute report recommended the following steps: 1) increased investment in broadband access, 2) support of nationwide interoperability, 3) deployment of new fraud detection methods, 4) broadening of regulatory relief, 5) continuing to leverage telehealth to address health disparities. The Current State Of Telehealth Evidence: A Rapid Review; Research Shows Patients and Clinicians Rated Telemedicine Care Positively During COVID-19 Pandemic; How to Make Telehealth More Permanent After COVID-19 Digital Therapeutic Companies Click and Pear Raise Growth Capital/Funding Event: Digital therapeutic (DTx) companies are growing more popular as the pandemic continues with several companies recently coming to market. Click Therapeutics, a DTx company that treats mental health disorders, raised $30 million through an investment of growth capital from K2 Health Ventures, while Pear Therapeutics, a company which treats substance use disorder, opioid use disorder, and most recently, insomnia, raised $80 million via a Series D funding with Softbank’s Vision Fund. These applications are defined by the Digital Therapeutics Alliance as “evidence-based therapeutic interventions driven by high-quality software programs to prevent, manage, or treat a medical disorder or disease.” These treatments undergo Food and Drug Administration (FDA) review and approval and may be over-the-counter or require a prescription. Description: Click Therapeutics, Inc. develops software and applications to treat unmet medical needs and uses an adaptive data science platform (Clickometrics) to personalize the user experience to optimize engagement and outcomes. Click currently has an industry-leading smoking cessation program available through payers, providers, and employers, and is also working on other high-burden therapeutic areas, such as Major Depressive Disorder (MDD), Schizophrenia, Acute Coronary Syndrome (ACS), Chronic Pain, Insomnia, COPD and Obesity. Click’s smoking cessation program has features like controlled breathing, social engagement, medication access and adherence, digital diversions, and financial incentives. Pear Therapeutics discovers, develops, and delivers software to improve outcomes for patients. Where it has products to treat substance use disorder, opioid use disorder, and chronic insomnia, it's also developing products to treat schizophrenia, IBS, pain, PTSD, migraines, and more. Pear patients can also be connected through the app to dedicated advocates there to support them through the treatment. reSET, the service that treats substance use disorder, provides cognitive behavioral therapy (CBT) as an adjunct to a contingency management system to increase abstinence from a patient's substances of abuse during treatment. Pear plans to use the recent investment to accelerate reimbursement coverage for its three products. Both Click Therapeutics and Pear Therapeutics are designed to be used independently or in conjunction with biomedical treatments. Implications: The biopharma space is transforming digitally and has garnered significant investment interest (with three of the larger DTx companies, Click, Pear and Akili Interactive, raising almost $750M from inception to date). With 9 DTx currently on the market (including those given clearance due to the public health emergency) the space is ripe for development despite the fact that CMS has yet to specify a clear path for reimbursement for these products and regulations appear to be lagging behind real world behavior. For example, the two largest pharmacy benefit managers CVS and Express Scripts have both launched digital formularies for the evaluation and reimbursement of such technologies, with CVS covering five such products. While reimbursement and efficacy standards remain issues to be addressed and solved over time we expect the regulatory apparatus to catch up to technological developments. Moreover, given that DTx are software based they present the potential for significant cost savings and applications to value-based care such as reduced development costs and risks vs. biopharmaceuticals, improved measurement and reporting of patient adherence as well as the potential for better patient engagement. DTx can also improve convenience by offering patients on-demand access to care, including the ability to treat and diagnose certain conditions earlier Click Therapeutics Secures $30M in Growth Capital from K2 HealthVentures to Expand Operations & Pear Therapeutics Raises $80M in Push for Reimbursement Amazon Web Services to Launch HIPAA-Eligible Data Management Service Event: On Tuesday December 8th, Amazon Web Services (AWS) announced the launch of HealthLake, a cloud storage, and analysis service available to healthcare and life sciences organizations. The service will allow organizations to store, tag, index, standardize, query, and apply and analyze data in the cloud as well as automatically structure information into HL7’s fast healthcare interoperability resources (FHIR) standard. Amazon views Artificial Intelligence in healthcare as potentially one of its next revenue drivers, and anticipates the market could reach over $19B by 2026 driven in part by demand for telemedicine and remote monitoring services. Description: The broad adoption of electronic health records and telemedicine has led to a dramatic increase in the amount of digitized health data in recent years however organizations are often unable to use sophisticated techniques such as machine learning to unlock insights into the data since data in medical records, like clinical notes, and forms (ex: insurance claims, x-rays, scans, labs) need to be prepped and standardized before analytical work can begin. HealthLake uses machine learning trained to understand medical terminology to identify and tag each piece of clinical information, index events to a timeline view, and enhance data with standardized labels so that providers can easily search all of this information. HealthLake automatically structures data into the FHIR format so that information can be easily and securely shared between health systems and with third-party applications. For example, clinical data is often siloed and incompatible even among departments of the same organization. HeathLake offers solutions to such problems and curtails cost burden and operability differences. Amazon noted that EHR vendor Cerner and population health IT vendor Orion Health have implemented HealthLake to address their data management needs. HealthLake’s potential lies in its ability to quickly ingest patient data from various diverse sources and transform the data to perform advanced analytics to unlock new insights and serve many initiatives across population health. Implications: With HealthLake, healthcare organizations can reduce the time it takes to transform health data in the cloud from weeks to minutes. Healthcare companies generate huge volumes of information, (ex: medical histories, medication and diagnoses records), however, given most of this data is unstructured and stored in different locations it can be difficult to match together and run analytics on. While healthcare organizations often build custom rules-based tools to automate the process of analyzing unstructured data and tagging clinical information, the systems often fail to gain complete insights because data needs to be standardized (ex: inability to account for spelling variations, typos and grammar errors). HealthLake can eliminate the need for organizations to build costly and complex analytics applications to discover trends and relationships in their data and make accurate predictions. HealthLake will join AWS’ other HIPAA compliant offerings including Transcribe Medical. Amazon Launches Service for Big Data Analytics in Healthcare & Amazon Launches HealthLake, a Platform for Storing and Analyzing Health Care Data Employee Benefit Trends in 2021: Diversity, Equity, and Inclusion Event: Recently, BenefitsPro published an article detailing “Employee Benefit Trends in 2021” noting that employers were focused on improving diversity, equity and inclusion. The article pointed out that as 2021 approaches, companies selecting employee benefit plans are expected to adopt new policy priorities for coverage. The values of diversity, equity, and inclusion (DEI) are experiencing increased interest on corporate boards as are an emphasis on environmental, social, and corporate governance (ESG). These priorities are expected to have implications for the composition of coverage employee health benefit policies. Description: Diversity has affected the content of employee benefit plans in the past, and experts believe that trend will continue. More varied needs for employees of different demographics include items such as transgender-related health services, in-vitro feritlization (IVF)/fertility coverage, mental health services, and adoption support. The pandemic exposed the needs of coverage equity in employee benefit plans. One-size-fits-all plans that leave little room for flexibility in coverage for employees with different priorities have not served everyone well. Single parents have separate needs than employees without children or with adult children. Finding childcare became an issue during the stay-at-home orders for parents of young children. Social benefits are also on the rise. Examples of these include elder and child care, as well as student loan repayment benefits. Adoption of these policies should continue and expand. Implications: The trend in prioritizing DEI in employee benefit plans has largely positive implications for the health and financial stability of employees in general. As employers have adjusted to working from home and other challenges of the pandemic, and with almost a year of experimentation under their belt they will be able to set standards and deliberately pursue strategies of greater inclusion remotely (ex: remote interviewing, remote internships). While the trend of more inclusive benefits was accelerated by the pandemic and the greater societal demands for social justice, the “trajectory towards inclusive benefits will continue and become increasingly prevalent and ...will permeate across all company sizes and industries”. Moreover, although one positive effect of the pandemic will be that employers will not be as limited by geography in recruitment and can attract a more diverse pool of talent, the pandemic has also “highlighted the need for better benefits for women, working parents as well as low-income individuals.” Employee Benefit Trends in 2021: Diversity, Equity and Inclusion How This New Jersey Health System is Training Physicians to Deliver Bad News Over Telehealth Event: On December 9th, Globe Newswire reported The Orsini Way, a healthcare communication company that focuses on improving patient experience and outcomes, is launching a new telehealth communication training program based on the “Breaking Bad News” program. This program is designed to teach medical professionals how to communicate difficult news more effectively with patients using telehealth solutions. With the increase in the use of telehealth platforms for the delivery of care during the COVID-19 pandemic, this will not only help to improve patient understanding of outcomes, but also improve patient provider relationships as well. Description: During these unprecedented times, healthcare professionals have been forced to pivot to telehealth platforms as their primary sources of communication with their patients. Along with communicating healthcare needs, they are also tasked with delivering difficult news to patients and their families. According to the article, research shows that 71% of patients have experienced a lack of compassion when receiving difficult news from a physician. As a result, Englewood Health, a leading hospital and healthcare system chose to become the first health system to participate in the Orsini Way telehealth communication training. The training is provided via video conferencing and includes improvisational actors playing patients to simulate real-life scenarios for healthcare professionals. Participants later receive their footage along with coaching sessions from certified instructors. The program is looking to expand to other healthcare organizations and recently launched new interactive and virtual learning modules centered towards improving overall communication and building relationships between patients and providers. Implications: The implementation of training programs such as this within healthcare systems, is essential for positive patient experience and outcomes. According to the article, residents at Englewood health now have greater confidence and skills to lead conversations with patients and their families due to the training. The article noted that many medical schools don’t typically prepare new practitioners to confidently communicate difficult news to patients and their families via telehealth. Therefore, to ensure that their teachings are timely and relevant to what is occurring in today’s society, training such as these need to be implemented to ensure confidence, compassion and positive outcomes. The pandemic has changed the vehicle medical professionals use to communicate with patients and it is important that health professionals are well-prepared. How This New Jersey Health System is Training Physicians to Deliver Bad News Over Telehealth & The Orsini Way Launches Telehealth Training Program Using Professional Actors to Teach Physicians How to Deliver Bad News Virtually

Eldertech Shifts Paradigm to More Complex Care for Seniors Our Take: COVID is busting the myth that seniors can’t or don’t want to use technology. Where there’s a digital divide between older and younger generations, older adults are gaining new tech skills during this time. Although eldertech (tech for the elderly) is in its infancy, it is growing fast in both application and market influence. With over $273M raised across 47 deals in the sector during the first three quarters of 2020 alone, investment funding is now the highest level since 2016. Moreover, given the risks and disproportionate impact of COVID on seniors in care facilities on top of the already existing desire by individuals to remain in their own home, demand for eldertech is growing dramatically. Seniors not only benefit from technologies that monitor their physical movements, activities, and physiological outcomes but also from technology that allows them to communicate with others. Where loneliness is linked to serious physical health effects, including increased risk of dementia, heart disease, stroke, and hearing loss, interactive apps help elderly people engage with others and remain mentally active. Description: As 90% of people want to age in the comfort of their own homes, there is a rising demand for technology to allow care providers to monitor and engage with the elderly remotely. For example, social isolation can be a major cause of mental illness and even death. Pre-pandemic, some 43% of adults aged 60 and older reported feeling lonely, according to a national study. This can not only lead to depression, but other health complications like dementia and hearing loss. Eldertech can play a role in bridging some gaps for seniors. Where it won’t replace the relationships that seniors have with other people or replace some of the things that are working well for them, it will enhance and augment what already exists. In addition, certain technologies can help compensate for certain effects of aging such as hearing loss. Advances in semiconductor and processing power have made these technologies much smaller and cheaper, so those who suffer from hearing loss would have the option to control the volume of their conversations and even eliminate background noise (through the use of advanced noise canceling technologies). While wireless monitoring technologies will not replace in-person caregiving, they can make a significant difference in the lives of older adults and help them live independently longer. Technologies used in institutional care settings can monitor weight (e.g. bath mat, mattress, bed), image (sensors embedded in cameras), location (location sensors and technologies including GPS, RFID, and Wi-Fi), and other health data through wearables (heart rate, oxygen levels). In addition, new technologies such as SmartSole, a monitoring technology, provides a smart insole to fit into shoes with a built in GPS that can be used to keep track of a loved one with dementia who may wander off and get lost. The device pinpoints the person’s whereabouts on a map, supplying addresses and outdoor locations to within 15 feet every five minutes. Remote monitoring technology allows the perfect balance of giving seniors independence they desire while giving healthcare providers and loved ones added convenience and ability to monitor their conditions and care. Giving seniors the freedom to stay in their home will allow them to age more organically and happily, and could hence help them live longer. Implications: Remote and virtual care technology is more cost effective, has better health results and is more convenient for patients and caregivers than institutionalized in-person clinica. For example research on hospital at home programs shows patients recover faster, have fewer complications and are more satisfied, while cutting costs by approximately one third. In addition, studies show that remote monitoring is more cost effective than standard care for certain high-cost conditions such as hypertension and congestive heart failure. A recent article in the journal Hypertension noted that self-management of hypertension with telemonitoring and self-titration was more cost-effective than usual care. Moreover, in a study by the Journal of Cardiovascular Electrophysiology demonstrated that while total outpatient and physician claims costs for implantable cardioverter-defibrillators (ICDs) were higher with remote monitoring, the average per patient-year costs were lower as was the cost-effectiveness ratio. While the use of remote monitoring and virtual care technologies have grown during the pandemic, providers and payers must remain conscious of the digital divide that exists in underresourced communities and work to combat this. A recent issue in JAMA indicated that as much as 41% of Medicare recipients don’t have an internet-capable computer or smartphone at home ,[please see our 9/8/20 blog article Access to Telemedicine Is Hardest for Those Who Need It Most]. Clearly, without broadband internet connection, patients are limited in using remote monitoring technology and the ability to digitally communicate to healthcare providers and this must be taken into consideration. In addition to being cost effective, remote monitoring enhances quality of life and care by allowing patients to enjoy the comfort, convenience and now safety of remaining in their own homes with studies noting that 90% of people want to age in their own home. In addition, with remote technology, health care providers can devote more time to in-person critical care. The combination of convenience, lower cost, and positive health outcomes will create a new market for remote monitoring technology even once the pandemic is over. Towards Responsible Implementation of Monitoring Technologies in Institutional Care; Pandemic Pushes Expansion of 'Hospital-at-Home' Treatment; Eldertech is In Its Infancy, but Growing Fast (subscription required for last article) Inside the Collapse of a Disrupter: How Haven’s High Hopes of Redefining Health Care Came to a Crashing Halt Event: On January 4th Haven, the highly touted partnership between Amazon, Berkshire Hathaway and J.P. Morgan designed to “reimagine employer-sponsored care”, announced that they would cease operations at the end of February. Since its founding in January of 2018 and despite the corporate pedigree and deep pockets of its backers, Haven had not been able to show much progress towards its stated mission and by all measures never measured up to its potential. According to those interviewed by STAT (and a number of other corroborated sources) Haven suffered from three major shortcomings: 1) a failure of a clearly defined mission, 2) a series of strategic blunders (poor CEO choice, competition between Amazon and Haven), and, 3) an inability to retain top talent. Description: As noted above, perhaps Haven’s biggest failing was that it “lacked a clear vision” and never truly elaborated “an actual reason for coming together and what they wanted to achieve”. While the company had a broad goal of providing” simplified, high-quality and transparent healthcare at a reasonable cost” to it’s combined employees, it never outlined the specific steps it would take to achieve these goals or how and by what metrics success would be measured. In addition, while Atul Gawande was a high profile, intellectually powerful voice as CEO he had never had an operating role at a business nor did he commit to taking leave from his other responsibilities to make what was effectively a startup his sole priority (where commitment and focus are key). Moreover, it appears the partners never clearly outlined what their contributions to the partnership would be nor what their commercial expectations were. For example, while all three companies had agreed to contribute funding and provide healthcare coverage for some segment of its population through Haven, Amazon appeared to be the partner most interested in creating a commercial opportunity in healthcare, noting at an AWS event in 2019 that healthcare could be one of its next major revenue drivers. Haven’s structure as a not-for-profit also made it difficult to incent employees to offer competitive compensation packages and non-cash compensation. Lastly, its highly secretive nature (perhaps a reflection of the Amazon influence) and poorly defined mission contributed to culture issues which made it difficult to rally employees behind its nascent mission and show them tangible progress. Implications: While it was believed such renowned names joining hands would make an impact to methodically fix the healthcare delivery system, the partners may have jumped in too quickly without acknowledging the unique nature of the healthcare industry. As noted, despite the significant financial and technical support, Haven’s vision wasn’t specific nor well defined. Moreover even with a clearly defined vision many would argue that approaching healthcare problems is best done incrementally, with a distinct goal. In the words of one observer, “a boulder-sized problem as big as healthcare cannot be solved with an equally sized sledgehammer solution. It is best done in moderation with a chisel, and over time”. As noted by Professor Erik Gordon of the University of Michigan’s Ross School of Business “the company might have benefitted from publicly targeting a well-defined chunk of the healthcare business such as pharmacy benefits or even access to primary care”. In addition, despite the presence of many large organizations in healthcare, “healthcare is always a local delivery and local financed industry...the challenge is always in aligning interests and goals''. Even then and even within organizations in the same geographies, healthcare challenges can vary widely among organizations. As highlighted by Kim Buckey, VP of client services at Direct Path, there is no one-size fits all approach. “Putting ideas into practice is truly individual to each organization-there is no one ‘right’ solution for every employer just as there is no ‘right’ plan for every employee. Given how heavily regulated, hierarchical and lethargic healthcare is one major lesson from the failure of Haven can best be summed up by Kate Brown of Mercer who said “in complex systems like U.S. healthcare, there is no single solution or entity that will deliver higher quality care at lower cost”. Inside the Collapse of a Disrupter: How Haven’s High Hopes of Redefining Health Care Came to a Crashing Halt & Goodbye, Haven: The Benefits Industry Reacts (subscription required for first article) Here Are 9 Predictions of What’s to Come in Startupland for 2021 Event: Noting that “venture capitalists make a living by trying to predict which startups and technologies may be the next big thing” Silicon Valley Business Journal recently ran an article highlighting many of the predictions they received from prominent venture capitalists for 2021. The predictions came from founders and directors of firms and tech experts sent into SVBJ. Description: While the predictions were varied and broad ranging (from construction to woman’s sports) the following had specific applications to emerging digital health companies. The push for diversity will grow, “ in 2018 Amazon adopted [a rule to interview at least one minority candidate] when filling board spots, and now additional companies are evaluating similar mandates as we continue to address social inequalities. Look for the private sector to take a giant step forward in 2021 with meaningful increases to executive and board-level representation.”-Michael Proman, Scrum Ventures The purported demise of the S.F. Bay Area exodus that has attracted so much attention during the pandemic will peter out next year. "Silicon Valley will continue to be the global center for technology innovation, but the rise of remote will pollinate many other parts of the U.S.-James Currier, Pete Flint, Gigi Levy-Weiss and Morgan Beller, NFX People ``who aren't currently working or who are working from home with plenty of time for thought and side hustles will create a tidal wave of new businesses…[while] in a post-Covid world—after a lot of time spent doing less, people will be eager to do more. Businesses will ramp up events to make up for what they couldn’t do in Covid. Las Vegas, convention sites, party and vacation space and more will see tremendous traffic.”-Ben Narasin, New Enterprise Associates “In 2021 we will see significant adoption of live and recorded video in enterprise learning, training, HR, sales, marketing and customer support. We predict that enterprise workers will interact with live or recorded Video more often than written communication soon."-Upal Basu, NGP Capital “Everyone will talk about [the election] but it won’t change their decisions. The factors that are driving societal change and technology adoption are more about the pandemic fallout and overall technology advancement and remote work trends.’-Issac Roth, Shasta Ventures "We see special purpose acquisition companies (SPACs) becoming the preferred choice for venture-backed entrepreneurs and venture boards given benefits in time, complexity and, now, ability to raise as much capital as a traditional IPO.”-Brian Walsh, WIND Ventures “The digitization of healthcare that we have seen this year will continue to grow after the pandemic: "Covid has driven up healthcare awareness across the nation. Consumers want to be able to see their health records, receive test results and access prescriptions digitally.”-Scott Francis, Fujitsu Computer Products of America Inc. Implications: While difficult to generalize, it is clear that a number of the impacts of COVID (as well as some of the social unrest during that time) will remain with us for a while including: heightened attention and efforts at improving diversity; the continued expectations and impacts of remote work (in whole or in-part) on employee quality of life and employer expectations; heightened use and access to video communication and collaboration tools to reduce distance and improve service; continued innovation in capital formation allowing private capital to further cannibalize public markets; and, the unstoppable impact of regulatory easing during COVID to propel the adoption and use of digital tools in healthcare. While it is always difficult to predict the future, 2021 will be additionally more difficult due to the uncertain timing of “the end” of the COVID pandemic and a return to what will become the “new normal”. Here are 9 Predictions of What’s to Come in Startupland for 2021 UCLA Health Develops Triage Process to Identify When Telehealth is Appropriate for Care Delivery Event: On December 30th, NEJM Catalyst reported UCLA Health’s development of telehealth-centered triage protocols to ensure that patients with specific care needs are assessed in-person and others facing less urgent threats are given the telehealth option. The careful consideration of patients needs will ensure that patents are receiving adequate and quality care, producing the best overall patient outcomes. Description: At the beginning of the COVID-19 pandemic, the U.S. Centers for Medicare and Medicaid Services (CMS) expanded coverage for telehealth resources. During a period of fear and uncertainty, this served as a major tool to ensure that patients still had access to the care they needed, despite the stay-at-home order. When researchers spoke with primary care physicians (PCPs) at UCLA Health on how transitioning to telehealth impacted delivery of care, PCPs agreed that the decision to deliver care through telehealth as opposed to an in-person visit should be based on careful assessment of the risks and benefits associated with each approach. According to the article, about 7% of all telehealth visits from March to September 2020 could have been considered inappropriate outside of a global pandemic. Concerns were also expressed regarding training, technology support, patient access to technology, data privacy and security, and clinical appropriateness. Implications: As the pandemic continues to surge, health systems need to reevaluate the best way to provide care to patients. As a result, the proposed use of a telehealth specific triage protocol to offer clear guidance on when to deliver care via telehealth versus in person care is certainly necessary. This concept was broken down into three steps- 1) Forming a multidisciplinary team that includes clinical, operational and financial stakeholders to take the necessary steps to increase the likelihood of high quality virtual care, 2) Taking into consideration the risks associated with both virtual and in-person, and consulting with providers, operators, and patients to identify key factors that indicate when virtual care is appropriate, and 3) Establishing performance metrics and collecting regular feedback from physicians, staff, and patients to improve triage protocols. With the implementation of this protocol system, this can help ensure that patients are receiving quality, appropriate, and reliable care throughout this pandemic and for years to come. UCLA Health Develops Triage Process to Identify When Telehealth is Appropriate for Care Delivery As Employee Mental Health Buckles, Nvidia Among Companies that Bolster Services Event: On January 6th, an article in the Silicon Valley Business Journal reported that Nvidia Corporation (Nasdaq: NVDA) employees had tripled the usage of the company’s confidential counseling services from 2% to 6% since the pandemic. The article notes the increased need placed on benefit teams to provide services that fit the needs of those seeking support for stress reduction and mental health support. Description: Since the COVID-19 pandemic, stress has been on the rise for many employees working remotely. A poll from the anonymous workplace app Blind found that 80% of employees at Paypal, Nvidia, Facebook, and Yahoo felt that remote work hurt their mental health more than their counterparts at ServiceNow, LinkedIn, and Oracle (74%). A report from Boston employee wellness company Wellable, Inc. found that 88% of employers are increasing investment in mental health programs, and 94% expect to expand virtual wellness services this year. New programs and strategies have been deployed at Nvidia that target the unique needs of employees who face stress and need mental health support. The company aims to provide easy access to employees to find counselors through their medical plan or Crossover Health, providing employee medical clinics and services to large companies. Additionally, telehealth services and virtual seminars are offered to employees to provide easy access to support services. Another strategy to reduce the stigma around mental health topics is having company leaders and managers talk to employees and share on topics such as time management and stress management. Implications: Given the increased stress incurred during the pandemic, employers have been placing even greater emphasis on prioritizing employee mental health and mental health services given recognizing that proper coping strategies can affect how we handle stress and respond to challenges. The article noted the need to destigmatize seeking mental health support to achieve better health outcomes. Many employees have adjusted to working remotely, but working remotely can have negative implications for their mental health due to social isolation and lack of interaction. This is especially true when employees are too timid to seek support services. Nvidia has also made accessing services easier by providing employees access to telehealth services and counseling offered via phone. These services offer several new options to access care given the range of employee needs and familiarity with counseling service. As noted in the article, with the right education, support, and access, employers can help employees reduce stress and lead healthier, more productive lives. As Employee Mental Health Buckles. Nvidia Among Companies that Bolster Services

Our Take: While non-traditional tech and retail disrupters in healthcare, like IBM, Walmart, Amazon, J.P. Morgan and Berkshire Hathaway (through the Haven joint venture), and Google, all had different goals in changing the face of healthcare, they have all had difficulty gaining significant traction the marketplace for similar reasons. These reasons include: reasons include starting too ambitiously with a poorly defined strategy; lacking distinct goals; failing to align their interests with patients and providers and, under or over-marketing their healthcare product. Description: Non-traditional, tech, and retail giants like IBM, Walmart, the Haven J.V. partners, and Google either recently or historically have all entered the consumer-facing portions of healthcare for different reasons. IBM built up and eventually branded its AI healthcare unit as Watson Health to use AI to improve health outcomes in Cancer and other diseases; Walmart planned to leverage its existing brand and retail store base to build 4,000 primary-care clinics initially focusing on underserved communities; Amazon, J.P. Morgan, and Berkshire Hathaway through the Haven joint venture attempted to reimagine the delivery of employer-based healthcare; while Google created Google Health back in early 2011 as a repository of health records and data (known as a personal health record) to allow patients to have access to all of their health records in one place. While all of these were worthwhile goals, many of them were too ambitious and poorly defined. For example, IBM focused Watson on curing cancer, as noted by Ariell Trzcinski, an analyst at Forrester, “these {were} really ambitious goals. One of the things we see with organizations that have been more successful in applying AI in healthcare is that they start small”. Similarly, one observer commenting on the collapse of Haven noted, “a boulder-sized problem as big as healthcare cannot be solved with an equally sized sledgehammer solution. It is best done in moderation with a chisel, and over time”. In addition, often these goals are very broad and lack a specific achievable goal. Walmart’s goal was to be “America’s neighborhood health destination” with a strategy that included a timeline of opening 125 clinics by the end of 2021, 1,000 clinics by 2024, and 4,000 by 2029, according to Business Insider. Along the same lines, IBM referred to Watson as a Cancer moonshot while Haven’s goal was “reimaging employer-sponsored care”. While we are not privy to internal projections which likely contain more explicit financial goals, the goals in these statements, though laudable, are not very specific in terms of treatment of distinct medical conditions or costs. In addition to overly ambitious and broadly defined goals, these initiatives often fail to align their interests and incentives with those of patients and payers. For example, according to Adam Bosworth the original leader of Google Health, Google never really pushed to see what people would want, they basically offered a place to store data. [People] want to be healthy but they need more than that. Connecting these efforts to the interests of payers is equally important, as noted by current co-founder and CEO of Health Rosetta and former Microsoft executive Dave Chase, “as much as we’d like to think it isn’t the case, the fundamental driver of most (not all) behavior in healthcare is the reimbursement scheme”. Likewise with Haven as one observer noted, despite the presence of many large organizations in healthcare, “healthcare is always a local delivery and local financed industry...the challenge is always aligning interests and goals.” Finally, not surprisingly given the importance of healthcare as a vertical for these disruptors, these efforts often fall prey to over-hyped marketing strategy. According to STAT+, IBM “announced a flurry of partnerships before it had the resources, the scientific evidence, and in some cases the technology to support them.” Similarly while Haven’s marketing team touted their goal of providing “simplified, transparent healthcare at a reasonable cost”, Haven’s partners never clearly outlined what their contributions to the partnership would be or what their commercial expectations were.” In the same vein, Google Health was poorly marketed and lacked support at the highest levels of the company to succeed. Implications: For non-traditional entrants like retail and tech entering healthcare and gaining market share in the consumer-facing aspects of the industry is difficult, time-consuming, and fraught with risk. The varied nature of healthcare data, the intricate nature of data privacy and security rules such as HIPAA and CCPA, and the often complicated relationships between patients, providers, and payers can make navigating the space difficult at best. While the technology is often steeped in a culture of “move fast and break things”, healthcare is infamously associated with Hippocrates and his oath to “do no harm”. As a result, achieving change in healthcare can be methodical, require broad consensus, and involve cross-collaboration support from broad swaths of an organization or parts of the industry. In the words of the former worldwide head of healthcare at Microsoft, “health is hard, it takes a lot of time, money and partners to transform an industry”. As a result, we recommend disruptors approach the market tactically with very specific, defined, and realistic goals to cure one problem. Innovators need to realize that success will breed success and drive internal demand from customers which can dramatically shorten the sales cycle. Moreover, while groundbreaking technology is wonderful, realize the limitations of the technology itself. For if the technology does not align with the customer’s problems or allow them to impact something under their control it likely will not succeed. In the words of Amit Kaushal, professor of bioengineering at Stanford, “having technology that works is necessary, but it’s not sufficient to ensure you’re going to alter clinical outcomes”. Lastly, disruptors must also identify their market strategy and be careful not to oversell their health products without inflating the capabilities recognizing that healthcare may be a very different market from where they are coming from. As noted by STAT+ “IBM failed to fully comprehend the differences between its traditional tech business lines and the complex world of health care." Goodbye, Haven: The Benefits Industry Reacts; 10 Reasons why Google Health Failed; Inside the Fall of Watson Health: How IBM’s Audacious Plan to ‘Change the Face of Health Care’ with AI Fell Apart; Walmart is Slowing its Ambitious Push Into Healthcare, Employees and Leaked Documents Reveal (subscription required for last two articles) MedPAC Recommends More Telehealth Study, Concerned About Fraud and Waste Event: An article from mHealthIntelligence describes the stance taken by the Medicare Payment Advisory Committee (MedPAC) relating to the future of telehealth coverage after the COVID pandemic. In the report, MedPAC did not endorse any final decisions concerning telehealth rules that were suspended during the public health emergency (PHE), instead suggesting that many temporary measures be extended so that they could be studied further. Description: On March 15th, MedPAC submitted its March 2021 Report to the Congress: Medicare Payment Policy to Congress that contains the Commission's recommendations on the future of telehealth coverage by Medicare. The report recommends that the telehealth coverage expansions that were put in place during the COVID PHE be extended for 1-2 years so that additional data can be collected to evaluate the impact of telehealth on healthcare costs and quality. During the pandemic limits on a number of telehealth rules including those limiting originating site requirements, cross-state licensure, and others were suspended or not enforced so that services that could not be safely delivered in person could be delivered. Importantly, the report recommended “Medicare should return to paying the fee schedule’s facility rate for telehealth services and collect data on the cost of providing these services” after the PHE ends, essentially returning to covering telehealth services at a lower rate than in person visits. In addition the commission suggested extending coverage for telehealth services regardless of originating site, (telehealth is often used to overcome distance for patients who cannot reach their provider easily), and recommended allowing clinicians to be allowed to bill for audio-only services (which were not covered prior to the PHE). In defending it’s recommendations MedPAC stated it prefers the continuation of this evidence-gathering period, over a permanent extension of all of the over 140 added telehealth services by the Centers for Medicare and Medicaid Services (CMS). It also recommended that providers no longer be allowed to waive cost-sharing for telehealth services. Implications: As noted by mHealth Intelligence, many will be disappointed that MedPAC did not embrace the alternative for permanent extension for the majority of the approximately 140 coding changes that it mentions. Many industry participants had hoped, and anticipated that the massive uptake in telehealth usage during the pandemic would lead to a shift in policy. While it is important to note that MedPAC's recommendations are not binding and it has no official role over CMS, the Commission's recommendations often carry much weight. In addition, if Congress and CMS do not act, once the PHE ends, certain limitations on telehealth services like those limiting originating site of services will go back into effect. Moreover, although the Commission is right to focus on the potential for fraud and abuse in telehealth, as demonstrated by success of telehealth during the pandemic, those concerns may be outweighed by the benefits that can be brought to patients, particularly the underserved. Though some have pointed to the recommendation for further evidence gathering and study noting disappointment, we believe the Commission’s recommendations indicate that some, but not all, of the regulation changes to telehealth services covered during the public health emergency will eventually be made permanent, but there are no guarantees. As we pointed out earlier, the Commission appears to be focusing only on direct costs and does not appear to be taking into account other indirect cost and the opportunity costs of lost improvements in care. While many of these are difficult to measure, they should be taken into consideration as we seek to broaden access with new, more innovative tools. MedPAC Recommends Limiting Post-COVID-19 Telehealth Coverage, More Study & MedPAC March 2021 Report to the Congress: Medicare Payment Policy Using Telehealth to Keep People with Developmental Disabilities at Home Event: Recently, Healthcare IT News reported on a plan that Partners Health Plan of New York has implemented to use telemedicine to decrease ED visits for its members. According to the report, Partners is a managed care organization that is dedicated to helping people with intellectual and developmental disabilities (IDD). It noted that those with IDD may experience trauma associated with hospitals, often can have difficulty dealing with change and may face discrimination or difficulties communicating. As a result, all of these issues can lead to people with IDD having negative experiences in medical settings. Description: Patients with IDD can “go downhill with hospital admission.” While IDD has not been among the fields to provide advanced technical support to patients, Partners had begun rolling out telehealth programs aimed at helping this demographic even before COVID. Partners was working with StationMD prior to other healthcare providers opening the telehealth platform for IDD patients. The telehealth program Partners implemented showed both hospital admissions and emergency room visits decline since 2018. Following the pandemic, their telehealth program reported 91.6% of calls were treated via telehealth itself and only 8.4% transferred to the emergency department. The pilot program for Partners and StationMD included providing residential staff members with stethoscopes, pulse oximeters, blood pressure monitors as well as equipping doctors with a detailed history of patients historical claims data. As a result, by the time the pandemic hit, the system was already in place. Given the success that Partners has had rolling out telehealth to its IDD population it looks forward to implementing urinary tract infection management as a continuum of at-home service. Implications: As noted in the article, 1 in 4 adult patients have IDD and approximately 50% of adults with IDD are frequent visitors to the emergency department. Their reported satisfaction to the ED is very low as they often face some sort of discrimination or challenges in an ED. While telehealth skyrocketed in popularity during the pandemic, concerns arose that telehealth could worsen the digital divide especially for people with disabilities since providing telehealth visits to patients with IDD was very new to providers. This new initiative by Partners Health Plan which sought to broaden the use of telehealth to people with IDD, while taking into account their unique needs and working closely with local providers, appears to have been a success. Not only has it allowed patients with IDD to have a positive experience it has also allowed them to experience it from the comfort of their own homes. Telehealth care for IDD patients indicates the use of such applications can support their particular communication needs which enables simple behavioral interventions and provides support in treatment. By creating multi-modal telehealth applications that are adapted to the health needs and capabilities of these patients, innovative care delivery teams like Partners are broadening the scope of care that can be delivered to people with IDD at home thereby improving outcomes and reducing costs. This approach, along with the development of AI based tools has the potential to revolutionize the care for patients with intellectual/developmental disabilities. Telehealth as a Tool to Keep People with Disabilities out of the Hospital Trialing an Edible Camera to Improve Detection of Colon Cancer Event: (3/11) A recent article in MobiHealthNews highlighted Medtronic's new Pillcam Colon 2 technology. The NHS in England will perform a trial to check for colon cancer signs among participants given the edible miniature camera. Description: A recent study by Oxford University noted that thousands of patients might have untreated bowel cancer as a result of diagnostic testing that was deferred during the COVID pandemic. Between April 2020 and October 2020, over 3,500 fewer patients than expected were diagnosed with bowel cancer in England. The Pillcam Colon 2 technology seeks to provide a quick, safe, and convenient approach to patients who have to monitor or test for colon cancer signs. The pill is a vitamin-sized capsule that is taken orally, does not require sedation, anesthesia, or radiation. Once swallowed, the camera-enabled capsule will take images as it passes through the bowel. The images will then be transmitted to a recording device that the patient wears. After the camera has passed through the body, it can be flushed away. The NHS plans to trial the pill by giving it to 11,000 participants in more than 40 areas in England to look for signs of colon cancer. The endoscopy team at University College London Hospitals NHS Foundation Trust, NHS in Scotland, and other international health clinics are already using Pillcam technology. Implications: The new and innovative Pillcam technology has the potential to replace the traditional endoscopy where patients are required to undergo in-person procedures to have a tube inserted. The Pillcam technology will provide a diagnosis within hours, speed up checks, and detect cancers at an earlier stage where they are easier to treat. Clinicians can remotely monitor their patients and provide the help and support they need in real-time. Since bowel cancer is more likely to be curable if detected at its early stages, this technology can make a clear impact on identifying and treating patients with bowel cancer. Innovations like the Pillcam Colon 2 technology can help the tens of thousands living with underlying symptoms and undiagnosed cancer due to routine screenings that have been delayed or skipped during COVID. This technology, and others like it, can provide a quick and efficient diagnosis to patients from the comfort of their own homes. NHS Trials Edible Capsule Cameras to Detect Colon Cancer

Our Take: The rise in substance use disorder (SUD) fueled by the opioid epidemic has increased demand for behavioral health services and exacerbated the behavioral health workforce shortage. There is a marked discrepancy between the number of people who need addiction treatment in the United States compared to those who receive it. According to the American Addiction Centers, approximately 21 million people (12 and older) need substance abuse treatment, and only an estimated 3.8 million people have gotten treatment, signaling that only 18% of those who needed treatment were able to access it. Innovations such as telehealth can provide lower-cost and widely available approaches to serve as an alternative treatment option for people suffering from SUD. Telehealth can connect geographically dispersed patients and providers and is a promising approach to expanding access to those suffering from opioid use disorder and other SUDs and seeking treatment. Utilizing digital tools through companies like Eleanor Health, Genoa, Pear, and Marigold can provide supplemental, individualized treatment plans that address challenges faced with SUB exacerbated by the numbers involved with the opioid crisis. Description: As noted above, less than 20% of those who need treatment for SUD actually receive it. Reasons for access limitations include a limited supply of rehab facilities, lack of specialty SUD treatment providers, lack of primary care physicians with experience in behavioral health treatment, and privacy and stigma concerns among those suffering from opioid and other addictions. Untreated drug and alcohol use contribute to tens of thousands of deaths every year and impact the lives of many more. While treatment providers possess a number of effective tools, including medications for opioid and alcohol use disorder, that could likely prevent many deaths, they are still not utilized widely enough. In addition, many people who could benefit from available treatments do not seek them out because of the stigma that surrounds addiction and addiction treatment. While less common, healthcare providers may consciously or subconsciously view a patient’s drug or alcohol problem as a sign of moral weakness which may lead to substandard care. For example, patients with indications of acute intoxication or substance withdrawal symptoms are sometimes expelled from emergency rooms because staff fear their behavior, which may appear erratic, or assume that they are only seeking drugs. As a result, people with addiction may internalize this stigma, become humiliated, and refuse to seek treatment which can lead to an inability to get control of their addiction and play a part in the vicious cycle driving these addictive behaviors. Given the ability to receive care without having to appear in-person or at any type of addiction clinic, telehealth for SUD can help reduce or eliminate this stigma. In addition studies indicate that telehealth can fill the care void as evidenced by the rapid increase in telehealth services during the pandemic which demonstrated that telehealth services are an effective adjunct and substitute for in-person care of SUD. For example, a study entitled, “How is telemedicine being used in opioid and other substance use disorder treatment” analyzed claims data from a large commercial insurer from 2010-2017. The authors found that the while the number of telemedicine visits for SUD from 97 to 1,989 (~1900%) during the same period general telebehavioral health visits increased from 2,039 to 54,175 (~ 2500%) implying telemedicine visits for SUD could be more broadly used. Increased use of telemedicine can allow patients with opioid use disorder to stay in treatment and receive counseling to further their recovery. In addition, broader use can offer patients, physicians, and the health care system as a whole enhanced convenience, reduced travel time, and cost savings and thus can be used as a useful substitute or additive treatment for patients suffering from substance use. Another study, entitled, “Telemedicine-delivered treatment interventions for SUDs: A systematic review” examined the delivery of substance use treatment via video conference. It assessed the clinical impacts on substance use, treatment retention, acceptability, and feasibility. The study found that telemedicine can be associated with improved treatment retention compared to participants traveling for in-person treatment. Another systematic review of behavioral health articles conducted in three regions (United States, European Union, and Australia) indicated that telemedicine was associated with reduced depression, decreased cost, and increases in patient satisfaction, accessibility, and quality of life. Interventions included mobile health, electronic health, telephone, and two-way video. While telemedicine can be a useful substitute or adjunct to in-person therapy, there are still two pressing issues that remain to be addressed: the delivery of Buprenorphine and training. Buprenorphine is a common medication used to treat opioid use disorder, acute pain, and chronic pain. According to the American Addiction Centers, 90% of the physicians who are approved to prescribe Buprenorphine practice in urban areas. About 53% of rural counties do not have any physician who can prescribe it, and rural providers who can prescribe buprenorphine report high demand, a lack of resources, and long wait times for patients. This issue is not likely to be addressed in the short-term via telemedicine, however, longer-term thought should be given to allow other clinicians to administer Buprenorphine under the guidance or remote management of more senior providers. Similarly training of additional clinicians to treat SUD will take time. For example, according to the American Society of Addiction Medicine, treating 20.7 million Americans with a SUD will require training that is too often lacking in our nation’s current addiction workforce. The society noted there are too few clinicians with the requisite knowledge and training needed to prevent, diagnose, and treat addiction. Recognizing this need, in 2016 Congress authorized a training demonstration program within the 21st Century CURES Act. The Act authorized $10 million per year and awarded grants to medical schools and federally qualified health centers to support training for medical residents, fellows, nurse practitioners, physician assistants, and others to practice in psychiatry and addiction medicine. Here too, innovative approaches using telemedicine may help leverage the capabilities of the system to address the shortage of providers. Implications: Telemedicine is under-utilized, despite having great potential for assisting recovery and treating patients with SUDs. Telemedicine allows patients with opioid use disorder to stay in treatment and receive counseling to further their recovery. A study conducted by Yang et al. showed that telemedicine offers additional benefits for patients, physicians, and the greater health care system through enhanced convenience, reduced travel time, and cost savings.[v] Due to the lack of treatment centers in rural areas, patients may have difficulty with transportation, particularly when in outpatient treatment that may require multiple trips to a treatment center each week. Public transportation is generally not as convenient or readily available in non-urban areas and patients may live a long way away from a program. Even where patients may have access to convenient and reliable transportation, cost may be prohibitive, making telehealth a much more cost-effective means of accessing care. Companies such as Eleanor Health and Genoa are developing innovative ways integrating value-based care and evidence-based medicine to deliver more traditional therapies for those affected by addiction and SUD to help them live healthy, productive lives. Companies like Pear Therapeutics, Marigold, and WorkIt Health are incorporating new digital therapeutic (DTx) approaches to improve patient outcomes through digital applications that can be made broadly available. These companies provide evidence-based therapeutic interventions driven by high-quality software programs to increase abstinence from a patient’s substances of abuse during treatment. Despite the limitations of current studies, the researchers conclude that telemedicine-delivered treatments are a promising alternative, especially when evidence-based treatments are not readily available. For specific treatment and substance use categories, mainly when treatment adherence is a key goal, telemedicine can result in improved patient retention and treatment adherence due to increased accessibility. There is limited evidence that digital recovery support services (telehealth) effectively deal with all substance abuse situations. More and more research has been done on the brain, and the impact of chemical imbalances and susceptibility to addiction is becoming more evident. For example, brain changes are substantially influenced by factors outside of an individual's control, such as genetics or the environment in which one is born and raised. Unfortunately, along with the breadth of the opioid crisis has come better understanding and treatment, yet still more needs to be done. More studies and additional research are needed to understand the opportunities and barriers for telehealth treating behavioral health. Further evaluation should be conducted to measure the impacts of existing telehealth services and programs targeted to behavioral health solutions. Researchers have concluded that much work needs to be done to get more people to use telehealth for addiction treatment. Alleviating stigma is not easy, in part because the rejection of people with addiction or mental illness arises from violations of social norms. Treating patients with dignity and respect is crucial for people across healthcare, from staff in emergency departments to physicians, nurses, and physician assistants. Everyone should be trained to care for people with SUDs compassionately. How Is Telemedicine Being Used In Opioid And Other Substance Use Disorder Treatment?; Telemedicine-Delivered Treatment Interventions for Substance Use Disorders: A Systematic Review; Telemedicine’s Role in Addressing the Opioid Epidemic(subscription may be required) Talkspace’s Controversial Reno Contract and How Users Could be Left Behind Event: Recently STAT+ reported on Talkspace’s controversial contract with the city of Reno, Nevada. Under the deal, the City of Reno decided to spend $1.3M of expiring CARES Act funding to provide Talkspace therapy services to virtually every resident, excluding children, free of charge, for approximately one year. According to the article the contract was the idea of Mayor Hillary Scheive, who was looking to help residents following a surge in deadly COVID cases and her own personal difficulties finding a therapist in Reno after she herself was “devastated after her brother and sister both died within weeks of each other.” Local therapists opposed the plan since they were not consulted, felt that Talkspace’s services were “therapy-lite” and that patients could be left stranded when the contract expires in December 2021. Description: As noted, the Talkspace initiative was headed by Mayor Schieve when the Mayor herself was in dire need of therapy but was unable to get an appointment for weeks and ultimately found help through the Talkspace app. Following her experience, Mayor Schieve consulted with Reno resident Kathryn Goetzke, who has been working on global mental health strategy as director of Mood Factory which sells wellness products and the International Federation for Research and Education on Depression (iFred) a non-profit. Following discussions with the company, a deal was worked out to provide therapy to virtually all residents of the city via Talkspace at the monthly rate of 55 cents per person for chat and monthly video sessions (which ordinarily the service would have cost $316/month). While Talkspace’s vision of catering to a wider range of people than typically reached by standard therapy was well received by some, there were still local therapists that were distrustful of Talkspace. The therapist's main concern was that the majority of Talkspace’s interactions would be via text-based therapy, and the quality of care delivered by the app as compared to what could be delivered in person. In addition, therapists were concerned that Talkspace could realize disproportionate profits from the deal if fewer than anticipated residents took advantage of the offer from the City. The local therapist’s were also concerned that by using Talkspace local residents could open a Pandora's box of deep psychological wounds that couldn’t be treated appropriately by Talkspace and that could potentially leave residents in the lurch without mental health services when the contract ended in late 2021. Talkspace and the City responded by noting “the company has 10 independent studies to back it’s approach” and was already looking at ways to transition patients once the contract ends. As of late March, Reno’s grand experiment with Talkspace had roughly 1,350 active users — people who had signed up for the service and communicated with a therapist. Implications: Apps like Talkspace have effectively managed to fill the gaps in the nation’s tattered mental health system. While the therapist community in Reno opposed the move, recognition has to be given to the fact that the state of Nevada ranked dead last in a composite score by Mental Health America for prevalence of mental health issues and access to care. Although the service may not have been ideal it did cater to people who otherwise may have opted out of seeking mental health care due to stigma, cost, or lack of availability. Moreover the conflict in Reno is indicative of the tension between making limited services broadly available and perhaps making more intensive services less widely available. For example, the Talkspace program provided services to 200,000 people while an alternative proposal by local therapists would have only provided services to 12,000 people. To us the solution appears to be somewhere in the middle. Apps like Talkspace make it simple to connect with therapists with the added convenience of services like text, audio, and video messaging and they are extremely cost-efficient. However, platforms like Talkspace are not going to replace therapy for those who need intensive therapy or treatment for complex conditions although they may help bring people into treatment or provide a bridge to care until in-person care is available. Moreover, the ability of app based platforms to serve patients in multiple languages makes care more appealing and available. However, even with the attractions, these platforms do have drawbacks. The requirement of a smartphone is a necessity which is a potential barrier. Also, patients requiring long-term therapy for serious conditions should not depend solely on these apps and the apps themselves must be able to provide transitions to more appropriate care when necessary. These app-based therapy provisions are not replacements for conventional therapy but the easy accessibility and convenience in regard to cost and easily available slots for appointments with 24/7accesibility with a licensed therapist can serve to fill the gaps for an overburdened mental health system. Inside the Battle Over Talkspace and a Grand Experiment in Mental Heal (subscription required) Google Cloud Healthcare Projects to Keep An Eye On Event: On March 30th, STAT+ reported on five Google projects to watch as it builds up the healthcare segment of its Google Cloud platform. The company is focusing on projects that more broadly deploy AI to “improve how doctors and hospitals manage and exchange health data” as well as how they “use it to predict medical problems and direct health systems resources”. The five projects include AI factory, Care Studio, tools to improve detection of cancer, augmenting telehealth, and improving the interoperability of health records. Description: One of the main goals of Google’s deeper push into healthcare is to simplify the complexities associated with creating an AI empowered digital transformation. The first project is to “build an assembly line for novel artificial intelligence tools in a partnership with the Mayo Clinic.” According to the article, Google and the Mayo Clinic are hoping to build new AI products that will improve patient outcomes and make care more efficient. These products include a tool to target radiation therapy, using AI to analyze radiology images to detect chronic disease, and creating a clinical assembly line for AI solutions. More important than the specific project, Google and Mayo hope to build a process for assessing and improving AI solutions against real world situations. Another project was Care Studio, which is meant to act like a Google search engine for electronic health records. According to the article, the idea is to allow clinicians to type a query into a search bar so they may retrieve everything in a patient's history by using the company’s method of routing complicated streams of data through one portal. Google notes that the software is designed to work in tandem with existing EHR software not to replace it. The company is also working with the U.S. Department of Defense to apply AI to improve cancer detection on lung and breast images. The goal is to improve the accuracy of diagnosis through early detection and reduce the incidence of false positives via more precise analysis or tumors and tumor biopsies. In more direct consumer facing care, Google is also working with Amwell to provide cloud services and AI tools to improve the customer experience. According to the article, Amwell will use Google technology to “automate the waiting room and check out processes, responding to inquiries, and help triage patients”. The goal of the project is to improve the quality of care while helping streamline the experience for patients. The final project reviewed in the article is interoperability of health records. As the article notes, currently there is no “seamless flow of patient information within the healthcare system, that [makes] it easier to trade [or] use to inform decision making”. The goal of the project is two-fold, to help hospitals and payers adhere with new federal rules that prevent information blocking making it easier for patients to get electronic access to their data, while at the same time advancing Google’s goal of moving data to the Cloud where it will be easier for organizations to exchange and access data via APIs, Implications: With the creation of these projects, Google is working to deepen its role in healthcare through its core competence of search. Each of these aim to improve patient/provider experience, navigation through medical records, and introduce new AI tools into healthcare. However, some have exposed Google and its partners to criticism around the steps taken to ensure data privacy and security, which will remain a core concern going forward. This is especially important during this era where more patients are having to use digital health platforms and looking for simple alternatives. Google and other new entrants are likely to be held to a higher standard as they prove they are worthy of patients' trust and as such have got to emphasize transparency and communication with both providers and patents as they work to improve the use of new technologies in the system. Google’s efforts will put them squarely in the cross-hairs of other tech and retail players such as Amazon, Walmart and Microsoft all of whom are working to gain share in healthcare. All of the players would do well to remember the recent words of one large hospital system CEO who noted that there is tons of data in healthcare but none of it is easy to get to! 5 Health Care Projects to Watch at Google Cloud (subscription required)

Our Take: Age-related barriers to using digital health services persist, despite the significant uptake and shift to digitized healthcare. Digital health companies that design user friendly services or products for the elderly could mitigate adverse health-related outcomes and worsened chronic conditions linked to usage barriers by addressing the age-related barriers. Technological literacy gaps seen amongst the elderly are worth considering in the design and implementation of digital health innovations for the elderly to ensure digital inclusion. Key Takeaways: Just 26% of internet users ages 65 and over say they feel very confident when using computers, smartphones or other electronic devices to do the things they need to do online according to a 2015 Pew Research Center Study. As noted by Dario Health President Rick Anderson “The pandemic pushed the digital health world forward at an expedited rate of 15 years in three weeks.” A 2021 survey from American Advisors Group found that “83% of respondents stated they feel safer at home compared to elsewhere, and 40% said their independence is the most important benefit of aging in place.” Tomorrow Health CEO Vijay Kedar states that “90% of senior citizens wanted to age in place (at home), making the home the highest value site of care.” The Problem: Digital health is becoming an integral part of healthcare. The COVID pandemic has brought many more digital health solutions into the mainstream as a method of receiving care, yet certain demographics like the elderly risk being left out. This is a result of the massive digital health information divide between the younger and older generations. For example a 2015 Pew Research Center study noted that roughly 73% of seniors would consider themselves confident in their ability to use electronic devices to do necessary online activities. Similarly a November 2020 study from AgeUK found that, 39% of over 65s [in the U.K.] don’t feel confident using a smartphone. Although the pandemic has shown that the elderly can engage and receive healthcare digitally, the existing technologies do not meet the needs of the elderly because it is lacking in seamlessness and usability. Digital health companies that value inclusion need to adapt the design and functionality of technological solutions to provide value-based care to elderly patients. The Backdrop: The significant increase in digital health adoption and utilization by the elderly triggered by the pandemic has pushed healthcare innovators to explore innovating frictionless digital health experience for older users. In addition, a 2021 survey from American Advisors Group found that “83% of respondents stated they feel safer at home compared to elsewhere, and 40% said their independence is the most important benefit of aging in place.” However, the gap in digital health literacy has posed a major challenge to digital health adoption compared to that seen among younger, more digitally native users. Many older adults may also face physical limitations such as hearing, sight or dexterity that might limit their use of devices. Digital health solutions that are intentional about creating user interfaces that are easy to understand and utilize could yield positive health outcomes for the elderly. For example, companies like VitalTech have developed smart wearable devices that use a cloud-based platform to improve patient health and wellness through connected care. In addition, smartwatches from consumer electronics manufacturers like Apple and Samsung are increasingly seeking ways to connect with or tailor products for seniors that can help them track vitals, send alerts for falls and even give daily medication reminders. VitalTech’s interface between the smartphone applications that accompany the smartwatch is viewable by family members and could alert them to any potential threats to the user’s health. Implications: Digital health solutions can have a significant impact on the health outcomes and well-being of seniors. With fewer in-person healthcare options combined with the risk of exposure to COVID, older people who have chronic health conditions are being persuaded to embrace them more readily. This alongside mobility issues or other healthcare needs are “increasingly willing to turn toward virtual health services and products so they don’t have to leave the home”. These technologies can be particularly helpful with certain chronic conditions like cardiovascular disease, where lifestyle modification and self-management of chronic conditions are critical to improving outcomes. Studies have shown the significant effects of mHealth interventions in improving cardiovascular risk factors, such as blood pressure control, smoking cessation, and physical activity.” Therefore, creating user-friendly, easy-to-use applications for senior citizens and younger generations alike is a key way to reduce adverse health effects such as chronic diseases like cardiovascular disease, high blood pressure, and blood glucose related conditions. Also, monitoring devices that allow for continuous tracking of elderly patients’ chronic condition such as diabetes and hypertension can help give a more continuous picture of a patient’s condition, which could lead to earlier preventive care or mitigate health risks for older adults. While the projected growth of the aging at home trend presents ample opportunity for digital health companies to target and invest significantly in digital health solutions, these solutions must be customized for them in order to achieve success. Related Reading: Seniors aren't tech averse. We're just not designing for their needs Barriers to adoption and attitudes towards technology Seniors’ Desire to Age in Place Remains Overwhelmingly Popular

Our Take: Creating more digitally engaged nurses and digital nurse leadership is integral to optimizing the benefits of digital technologies and solutions in nursing practice. Digital health technologies and solutions have become an essential part of healthcare delivery and is widely debated to be the future of healthcare. Nursing is not left out with opportunities to explore the potential of utilizing technology or digital health solutions. The accelerated pace of adoption of disruptive digital health innovations demands that nurses remain at the forefront of digital innovations in patient care. Different countries all over the world are taking deliberate steps to elevate nursing leadership in the digital sphere. In its policy agenda the U.S. cannot be left behind. Key Takeaways: Despite the many benefits of digital health innovations in nursing practice, nurses have been reluctant to adopt technology because of inadequate support, complicated systems, and technological lapses. As noted in one study “nurses provide about 80% of care and are described as a link between patients and processes.” The top nursing challenges are nurse retention (61%), nurse recruitment (59%), nurse engagement (35%), and nurse leadership development (33%) per the 2017 Health Leaders Media Nursing Excellence Survey. Lack of nurse leadership poses a major challenge to nurse engagement with digital technology. The Problem: Globally, there was a massive increase in nurse shortages and poor retention that worsened during the COVID-19 pandemic because of theincreased health risk and inadequate support. In a 2017 survey, respondents ranked nurse retention as the top nursing challenge, followed by nurse engagement and nurse leadership development. Interestingly, the response from the survey revealed that engagement and leadership development drive nurse retention more than money. Digital health technologies and solutions have become increasingly adopted and integrated in healthcare with promises of transforming healthcare by reducing workloads, making processes simpler, and improving access and patients’ experience. It has benefits for improving nurse retention and overall performance with features that allow flexible scheduling and improved communication. Despite the many benefits of digital health innovations in nursing practice, nurses have been reluctant to adopt technology because of inadequate support, complicated systems, and technological lapses. Nurses' concerns about technological lapses and outdated systems have validity because the resulting disruption of work processes endangers patients’ lives. The Backdrop: Digital technologies like wearables, telehealth, remote patient monitoring, and scheduling apps have become integral to healthcare service delivery and are projected to remain part of the future of healthcare. Nurses who are at the forefront of implementing these technologies have experienced difficulties in adapting to this new normal. A major constraint contributing to poor nurse engagement with digital technologies is inadequate support caused by gaps in nurse leadership in digital health innovation. . While nurses are not averse to digital engagement, encouraging their active engagement in the technology development and implementation is fundamental for improved performance of these innovations. In addition, this appears to be an area in need of greater research focus. For example, as noted in “Artificial Intelligence in Healthcare: Implications for the Job Design of Healthcare Professionals”, most of the studies around AI and job design noted “the implications for job design …for doctors and patients but only seldomly for 1) nurses, 2) managers and 3) organizations” which the authors found “surprising as nurses provide about 80% of care and are described as a link between patients and processes.” In addition, while in many cases AI assistants are designed to help reduce workload, as the aforementioned study notes, “with the advent of digitalization and novel technologies, doctors and nurses must process much more information about patients and scientific publications, thereby both increasing and decreasing their job demands. Keeping up with such medical information, which is doubling every 5 years, is an example of an increased job demand.” Implications: The accelerated digitalization of health services and systems has expanded healthcare leadership responsibilities to developing and managing digital health. Nurses’ participation in implementing digital transformation projects at an early stage makes them central to digital healthcare leadership. As a result, empowering and enabling nurses to engage with digital tools is crucial for several reasons. When nurses are involved in the design of digital solutions, it helps in factoring complexities and peculiarities of different sector needs. For instance, community nurses might face more hurdles to using technology, especially if the systems are outdated or in instances where communities lack access to basic technological infrastructures or poor internet connectivity. Furthermore, technologies that are not fit for purpose pose a major barrier to nurses’ engagement with technology. Nurse leadership in the digital health space could lead to useful feedback on improvements in technologies and systems that would better serve the nurses and improve patients’ outcome. Moreover, enhanced communication between caregivers and caregivers and patients is another benefit. As noted above, nurses provide the majority of patient care and are an integral part of any design changes in the process of care for patients. Nurse leaders speak a language that other nurses understand and they are also better placed to address the concerns that they might have. For instance, concerns about reduced interactions with patients caused by uptake in technology can be addressed by flagging areas in which technology saves time or provides useful data for improved patient interactions. Implemented correctly, digital health solutions have the potential of alleviating many of the administrative demands of the nursing profession, however, nurse leaders need to be at the helm for sustainability and for better buy-in and adoption. Related Reading: Nurses 2.0 - The digital transformation of nursing Leadership in Digital Health Services: Protocol for a Concept Analysis How the nursing profession should adapt for a digital future Digital engagement in nursing: the benefits and barriers Artificial intelligence in health-care: implications for the job design of healthcare professionals

The Driver: Sidekick Health recently raised $55 million in series B funding led by London-based Venture Capital firm Novator Ventures, with additional participation from Wellington Partners, Asabys Partners, Frumtak Ventures, and a US-based partner that has yet to be revealed. Sidekick Health is an Iceland-based digital care platform focused on managing chronic diseases. Sidekick develops personalized digital therapeutics to encourage lifestyle and chronic disease management in a game-like format. During the COVID pandemic, Sidekick collaborated with the Icelandic government by providing remote triaging, remote monitoring, and management of COVID infections. The funds from the Series B funding will be used to develop additional treatments, further expand the platform to other countries, strengthen existing partnerships, and create new partnerships with stakeholders in the healthcare industry. Key Takeaways: 90% of the nation’s $4.1 trillion in healthcare expenditures are for people with chronic and mental health conditions according to the CDC. Nearly half (approximately 45%, or 133 million) of all Americans suffer from at least one chronic disease, and the number is growing. The DTx platform has helped 40,000+ patients globally at this stage, with its products currently available in six languages. A recent Frontiers in Public Health article found digital interventions can effectively improve the management of pain, fatigue, stress, and increase overall health-related quality of life. The Story: The Iceland-based startup Sidekick Health was founded by CEO and Co-founder Dr. Tryggvi Thorgeirsson and Dr. Saemundur Oddsson in 2014. The two doctors worked for years treating patients with lifestyle-related illnesses. They noticed that 68% of all deaths were related to lifestyle-related illnesses. This led them to pursue innovative ways to prevent chronic illnesses as well develop treatments for those already suffering from the diseases. The solution they came up with was to create a platform that combines behavioral economics with games, and make it scalable across multiple therapeutic areas. The product they created became the digital therapeutic platform called Sidekick. Sidekick’s go-to-market model is business-to-business (B2B) meaning it is designed to work with health insurance and pharmaceutical companies. Currently, Sidekick has partnerships with U.S-based health insurer Anthem to provide “digital first” care programs and pharmaceutical companies Bayer and Pfizer to develop a combination therapy using molecular drugs and digital therapy. With the funds from the fundraising round “Sidekick plans to double [the size of its] team from 120 to 240 team members across our four office locations.” The Differentiators: One thing that sets Sidekick apart from many of its competitors is its “integrated combination therapeutics consisting of a molecular drug and a digital therapeutic.” As noted in a recent TechCrunch article Sidekick’s approach used “digital therapeutics plus pills…that is designed to support healthcare outcomes by applying personalized behavioral lifestyle nudges, alongside clinical treatments like drugs, to augment, extend and support patient care for a range of chronic diseases and conditions”. As pointed out by Fierce Healthcare, “the digital platform features the Sidekick Health app for the patient, a care portal for HCPs to remotely monitor patients with communication and support, and what the company calls the DTx studio, where a team of doctors, nurses, physiotherapists and clinical experts create the portfolio of therapeutics.” In addition, “Sidekick works closely with pharmas …in creating auxiliary DTx programs to complement traditional drug treatments. There is also a strong connection with patient advocacy organizations to ensure the recommended treatment follows those groups’ guidelines. The application itself is free to use, however members will need a code for specialized features such as the Rheumatoid Arthritis program. Sidekick develops programs for a number of lifestyle diseases such as diabetes, ulcerative colitis, and smoking cessation. According to the company they “are building toward a portfolio of over 40 medical-grade digital therapeutics by 2026, and currently have 18 in Research & Development, with a total of 14 commercial partnerships secured so far”. They also have collaborations with other companies to bring new treatments and programs to their platform. The Big Picture: Sidekick Health’s solution shows that there is potential for digital health solutions to extend the life of traditional therapies as well as create new, innovative, efficient therapies that can enable more people to access personalized DTx and lifestyle management programs. The Sidekick platform will add to the growing number of DTx resources, expanding the reach of digital health. Insurance providers can work together with Sidekick to create other app-based therapies targeting chronic diseases. Since Sidekick will also be working with pharma companies, they will be able to create combination therapeutics as a way to increase adherence and effectiveness of treatments. The Sidekick app aims to improve the efficiency of digital therapeutics by adding a game-like element to health management which effectiveness has been proven and can be less costly to develop than traditional pharmaceuticals. The success of Sidekick’s solution is dependent on evidence-based evaluation on the effectiveness of these treatments. Research has been shown to support the idea that digital lifestyle programs can improve individual health outcomes. If evidence shows that Sidekick’s digital programs are effective, then more countries may adopt this type of treatment. Sidekick Health grabs $55M for digital-first care programs ; Digital therapeutics firm Sidekick lands $55M in Series B round, Health and Economic Costs of Chronic Diseases; An Empirical Study of Chronic Diseases in the United States: A Visual Analytics Approach to Public Health, Sidekick’s Feasibility Study Shows Encouraging Results for Breast Cancer Patients

The Driver: Clipboard Health recently raised $30 million in Series C funding led by Sequoia Capital with participation from Caffeinated Capital, Initialized Capital, Michael Seibel of Y Combinator; Tony Xu, co-founder of DoorDash; and Emmett Shear, CEO of Twitch. This latest funding round brings the total funds raised to more than $90 million. Clipboard is an app-based marketplace company whose goal is to serve as a solution to the labor shortage at healthcare facilities around the country. Their marketplace provides nurses and certified nursing assistants (CNAs) the opportunity to find work wherever they go through their application. This platform is as much for hospitals and nursing homes as it is for healthcare workers. Clipboard Health will be using the recently earned funding to hire new workers in all areas, including sales and marketing, and to double the size of its engineering team. Key Takeaways: Since March 2020, the number of people working at U.S. hospitals declined by more than 2%, according to data from the U.S. Bureau of Labor Statistics, while emergency department wait times increased. A recent analysis of workforce data by Premier found that staffing shortages cost hospitals $24 billion during the pandemic. 3 in 10 healthcare workers considered leaving their profession and 6 of 10 remarked that pandemic-related stress hurt their mental health according to a 2021 Kaiser Family Foundation study. Clipboard Health’s application allows for healthcare workers to find flexible shifts and for hospitals to find skilled healthcare workers. The Story: Founder and CEO, Wei Deng, started Clipboard Health in 2016 with a mission to revolutionize the market for healthcare talent by leading the way in reliability, affordability, and ease of use for facilities and healthcare professionals. For years, the healthcare profession faced a severe shortage of workers leading to facilities having to outsource their employees. The shortage of staff was made more apparent during the Pandemic when many hospitals were at full capacity and the number of people working in hospitals declined by over 2% in part due to COVID illnesses and disputes over safety protocols. Clipboard Health is an ideal solution to provide those facilities the ability to find qualified workers in less time. This easy-to-use application is organized so that healthcare facilities can post available shifts and qualified healthcare workers can find and register for those shifts. According to TechCrunch, “Clipboard, is an online marketplace that pairs nurses, nursing assistants and other healthcare professionals with facilities in need of staffing. Using the platform, facilities can post shifts they need to fill and healthcare workers can book these shifts, managing their schedules via Clipboard’s mobile app.” Clipboard is easy to access and like any smartphone app, providers and healthcare workers can find this application in the app store for Apple devices and the play store for Google devices. The Differentiators: Clipboard differs from similar companies like Trusted health which created a platform for nurses to find contract positions and ShiftMed which allows healthcare workers to find available shifts through the app with next-day pay. Clipboard is unique in that it does not require healthcare workers to apply for a contract or long-term position at a particular facility. The healthcare worker can choose shifts anywhere in their area using only their mobile device. The feature of Clipboard that particularly stands out is the instant pay after the shift ends. Healthcare workers are typically paid weekly, bi-weekly, or the next day when working as employees or contractors, however, Clipboard allows healthcare workers to get paid much faster than traditional methods. In addition, Clipboard prides itself on providing flexibility to its consumers to reduce worker burnout and creating a healthcare marketplace of talented workers for facilities. The Big Picture: Clipboard Health’s solution of an online marketplace for healthcare providers has the potential to become a model for helping alleviate the workforce shortage in healthcare by making it easier to advertise and fill available positions. Clipboard’s app approach can benefit hospitals, nursing homes, nurses, CNAs as well as the patients they serve. The company’s solution allows hospitals and nursing homes to be more efficient in recruiting and filling vacant positions by increasing access to talented healthcare professionals quickly and easily. Providing nurses and CNAs with access to numerous opportunities in their local geographic area and on their own time can help reduce stress on the healthcare worker and benefit the patient by having caregivers who are engage, satisfied and rapidly rewarded financially for their efforts. In addition, as noted in numerous studies, less burnout and greater job satisfaction with their jobs translates into higher quality, more attentive care for patients. Over time this becomes a virtuous circle, the more providers that Clipboard works with, the more opportunity for the workers and the better results. However, maintaining these levels of success and ensuring Clipboard’s solution is effective will likely mean the company will need to expand its network of providers andservices geographically and diversify the number and types of shifts offered. Moreover, one additional challenge Clipboard may face is the robust competition within healthcare for talent between providers, travel nursing companies and other types of contractors. For example, while Clipboards model is differentiated, there are several companies such as NurseDash, CareRev, NomadHealth, and ConnectRN that have similar models that could pose strong competition if Clipboard’s model does not further differentiate itself. For Clipboard to stay competitive, it may need to extend its list of service offerings to other healthcare professions such as medical assistants, physician assistants, and physicians themselves if it is to succeed long-term. Clipboard Health, which matches health workers with facilities, raises $80M; Clipboard Health, an online hiring platform, snags $80M to expand into more cities; Healthcare staffing startup Clipboard Health raises $80M across two rounds and more digital health fundings

The Driver: Evernow recently raised $28.5 million in a Series A funding led by NEA, with participation from 8VC, Refactor Capital and Coelius Capital, plus angel investors, among them Color CEO Othman Laraki, and Carla Harris. The San Francisco based company built its platform focusing on women’s health and more specifically those who suffer from adverse symptoms of perimenopause. The company claims its using its clinically-validated health intakes to fill gaps in care for menopausal women while being inclusive to women from all backgrounds especially in underserved communities. The new funding will be used for expanding the team, building community, and leveraging the company's data and research to focus on product development. Key Takeaways: There are an estimated 1.3 million women entering into menopause every year in the United States. This equals to over “$2,100 per woman per year” in added costs on the healthcare system and overall economy. Black women, in particular, have reported longer-lasting and more severe menopause symptoms than other racial groups for years. A subscription includes unlimited access to the startup’s medical team and the delivery of hormone therapies estradiol or paroxetine, supplemented with progesterone when needed. Although funding has increased for women’s health start-ups overall, it still remains a relatively small portion of the digital health investments. The Story: Menopause is defined as as the end of a woman’s menstrual cycle and is diagnosed after a woman has gone 12 months without a menstrual period. Perimenopause is defined as the process of Menopause beginning which most women start in their 40's and is evidenced by skipped cycles and period irregularities. Alicia Jackson, founder and current CEO of Evernow stated that the company’s goal is to “build a new way of delivering healthcare based on science, innovation, and women’s lived experience with menopause”. Established in 2019, Evernow’s goal is to serve as a link between women who are or are about to reach menopause and a team of specialists who can advise and prescribe to them. Evernow aim to provide a resource for the approximately 1.3 million women just beginning the process and entering the perimenopausal phase, a process that spans 10-20 years of their life, produces symptoms for 85% of patients, and yet where there are very few viable options for treatment and management. Studies have shown that women who experience menopause are more likely to be at higher risks for cardiovascular disease, stroke and osteoporosis. As noted by the Office of Women’s Health at the U.S. Depatrtment of Health and Human Services, low levels of estrogen and other changes related to aging (like gaining weight) are indications of these conditions making it crucial in addressing the symtpoms of those who are most at risk. For example, in a survey of 100,000 women experiencing menopause who filled out Evernow’s intake form, 75% of perimenopausal women reported experiencing fatigue and low energy, weight changes, sleep disruption and brain fog. Almost two-thirds of women (60%) reported anxiety or depression, night sweats, hot flashes and joint or muscular pain. The Differentiators: While there are many healthcare companies targeting women’s issues, sometimes referred to as “Femtech”, their efforts generally focus on sectors catering to women under 40 such as pregnancy and fertility, but far fewer focus on the issues of women undergoing the three phases of menopause (Perimenopause, Menopause, and Late Menopause). Evernow is focusing on menopausal issues and trying to make access to education and the necessary treatments to manage the symptoms of this phase of a woman’s life more effective and discreet. For example, although there are a number of tools to address either the physical or the behavioral aspects of menopause, Evernow provides both hormone therapy, like the estradiol patch or pill, and paroxetine as well as an SSRI that can be used to treat night sweats and hot flashes. In addition, when users sign up for the service, they're matched with a clinician who helps build their treatment plan based on the patient's health history and their medications are unobtrusively delivered to their homes. The user is alsl given access to a library of resources and guides aimed at educating not-only women currently experiencing menopause, but also the millions of perimenopausal women who are transitioning into the menopause phase. According to the company, treatment data is based on its studies of more than 100,000 women experiencing perimenopause and menopause symptoms since its founding in 2019. Also, the company is backed by influential female celebrities such as Gwyneth Paltrow, Drew Barrymore and Cameron Diaz who are known for their activism on women’s health and rights. According to CEO Jackson, “women going through the healthcare system understand where the gaps are in a way that I don’t think men do.” Members pay between $75 and $129 per month for the services which are seemingly cheaper than that of similar companies such as Parsley Health, which offer their subscriptions for approximately $175 per month (however, Parsley does offer out-of-network reimbursement up to 70%). Evernow accepts Health Savings Account (HSA) and Flexible Spending Account (FSA) since they are not in network with any insurance providers. The Big Picture: Investors spent $1.023 billion on U.S. women’s health technology startups in 2020, up from $625 million in 2019, according to Crunchbase data. Investment in this space has steadily risen since 2017, with total funding of $2.9 billion since 2016. As the industry shifts its focus to an older generation of women, it is evident how neglected they were. According to the company, while over 55 million women publicly and secretly experience menopausal symptoms, over 75% of those who seek help seldom get it. This appears to be due in part to a lack of attention from the healthcare industry. For example, according to an article by Fortune, of the millions invested in technology for women’s health over the past decade, only 5% has gone to menopause management. Consequently, as the numbers increase for women who are approaching perimenopausal age, there needs to be more talk and concern surrounding this health issue and the health disparities that accompany treatment. In addition, many of the issues associated with menopause such as cardiovascular disease and stroke often disproportionately affect women of color, so addressing the issues and concerns of underserved communities should be a priority in disease prevention and management. Evernow, and companies like it, are actively taking the steps to address the concerns of millions of women by offering its 24/7 communication services with their clinicians as well as guaranteeing improved conditions for night sweats, and hot flashes among much more in under 3 months. Treatments like this which increase the convenience and accessibility care for menopausal women can improve the quality of life as well as reduce the risk of other health complications that would further burden an already distressed health care system. Clearly many women can directly benefit from utilizing such a platform and it would give them a greater degree of control over their health. Gwyneth Paltrow, Cameron Diaz-backed Evernow raises $28.5, It’s Time to Prioritize Menopause: Our Investment in Evernow (Note: authors are employees of NEA, lead investor in the company)

The Driver: The AI-programed Dental care company VideaHealth recently raised $20 million in Series A funding led by Spark Capital with participation from Zetta Venture Partners and Pillar VC. This latest funding round brings the total funds raised by VideaHealth to $26.4 million. VideaHealth’s software helps detect dental pathologies that the dentist may miss. They hope to make this type of AI a standard part of dental care by assisting dentists in their clinical diagnosis and ensuring quality dental care for their patients. We beleive that over time AI-based dental tools like VideaHealth can be used to extend care to many currently lacking care through the use or dental hygienists or other professionals under the supervision of a dentist using their platform thereby eliminating or reducing the number of people lacking access (our theory not currently a strategy of Videa’s to our knowledge). This would impact reduce the chances of developing poor dental health and pathologies. Key Takeaways: Oral conditions affected 3.9 billion people and “$244.4 billion of the expenditures occurred in high-income regions” per the Global Burden of Disease study. The populations most prone to oral diseases are also the most vulnerable: the poor, the very young, the elderly, those with disabilities, and those with comorbidities. VideaHealth AI software works like a second pair of eyes to help dentists diagnose oral diseases and works to help do diagnostics and practice management. Currently, dentists miss up to 50% of oral pathologies in dental diagnostic imaging. The Story: The founder and CEO, Florian Hillen, founded VideaHealth in 2018 with a mission to improve patient health using artificial intelligence. Videa is harnessing the power of AI to make dentistry more transparent to dentists, insurance providers, and patients. The company was founded to overcome the high rate of missed diagnoses in the dental industry. A study published in 2011 by Dr. Ida Kondori, then at Xavier University, found that 43% of clinical diagnoses submitted by dentists were incorrect. That means that almost half of the patients were not receiving an accurate diagnosis. Similarly, Kondori and colleagues found that “General dentists misdiagnosed 45.9%, oral and maxillofacial surgeons 42.8%, endodontists 42.2%, and periodontists 41.2% of the time”. Hillen and partners recognized these high misdiagnoses rates and subsequently developed a tool to combat this. To accomplish this, the AI program is trained on data from millions of patient records from images that have been previously reviewed and labeled by dental experts. By analyzing these records, the program can identify and measure clinical indicators on x-rays to provide an accurate diagnosis. Although the company is for-profit, most of the money generated comes from venture capital investments. The Differentiators: Videa is one of the early companies aiming to apply artificial intelligence to the problem of dental diagnosis and aims to reduce the percentage of dentists misdiagnosing patients by utilizing AI dental software. Videa is different from other dental services like Quip which is involved in the design and delivery of oral care products and Pearl Inc which provides AI analysis which attempts to either support or refute a diagnosis (as opposed to capture a potentially missing diagnosis or improper treatment). Videa's solution is unique because it’s a digital resource used by dentists to improve diagnosis accuracy when seeing patients. With the proper usage and development, their software may be able to improve overall oral health outcomes. This is extremely important as noted in a recent article in BMC Human Resources for Health “the combined worldwide direct and indirect costs estimated [for oral health conditions are] near $442 billion USD annually and “the populations most prone to these diseases are also the most vulnerable: the poor, the very young, the elderly, those with disabilities, and those with comorbidities.” The Big Picture: Videa’s dental tool AI is one of what is expected to be many digital health tools that could play a role in oral health. Moreover, we expect the recognition of good oral health to gain prominence as a prerequisite to strong physical and mental health. Those lacking in good oral health often cannot eat certain foods that help their diets which in turn contributes to other health issues. In addition, missing teeth or poor gums, can also contribute to poor self-image which can contribute to social isolation leading to other behavioral health issues. As noted in “Improving Access to Oral Health Care for Vulnerable and Underserved Population”, “access to oral health care is essential to promoting and maintaining overall health and well-being, yet only half of the population visits a dentist each year…the consequences of these disparities in access to oral health care can lead to a number of conditions including malnutrition, childhood speech problems, infections, diabetes, heart disease, and premature births.” In addition, as noted above, the cost of poor oral care in the U.S can be associated with almost $500B in disease. The Global Burden of Disease study reported that oral conditions affected 3.9 billion people. [Tooth decay] and periodontal disease are the most prevalent oral diseases globally and that “$244.4 billion of the expenditures occurred in high-income regions including North America, Western Europe and Asia-Pacific”. Tools like VideaHealth can not only make practitioners more effective it can also potentially broaden the delivery of care by improving e the efficiency of dental providers in making an accurate prognosis. In areas where providers are scarce this could help address the social determinants of health associated with oral care by reducing the number of people who will not have access to Videa’s platform. Accuracy of dentists in the clinical diagnosis of oral lesions, VideaHealth raises $20M for AI-enabled dental care

The Driver: This week Wheel raised a $150M series C round bringing its total raised to $216M since the company was founded in 2018, and follows the company’s $50M series B just last May. Wheel’s fundraising round was led by Lightspeed Ventures and Tiger Global with participation from existing investors CRV, Silverton Partners, and Tusk Venture Partners. New investors Coatue and Salesforce Ventures also joined the round. According to the company, it will use the funds to continue to grow headcount, broaden its virtual care platform, particularly in diagnostics, as well as expand its onboarding and educational programs. Key Takeaways: According to the Austin Business Journal, Wheel had twice the number of patent visits in Q4 2021 as it did during all of 2020. According to Wheel internal data, standing up and scaling a virtual care service on your own costs an average of $15MM and takes approximately 15 months. The McKinsey 2020 Virtual Care Study claims that approximately $250B or ~20% of all outpatient, office, and home health spend, could potentially be virtualized. A study by Nuance and HIMSS found that 97% of doctors and 99% of nurses surveyed had experienced burnout at some point in their working life. The Story: According to Forbes, the idea for the creation of Wheel goes back to when CEO and co-founder Michelle Davey was a child and had to undergo over a decade of being “ferried between doctors for her to be diagnosed with an autoimmune condition.” After several stints working in healthcare and recruiting, Davey returned to healthcare to work at a telehealth startup to do recruiting. Thinking her previous recruiting experience would give her a leg up in her new role, she was quickly surprised to learn that it had not. In 2018 this led Davey and her co-founder Griffin Mulcahey to found a matching market for virtual healthcare providers called Enzyme which subsequently became Wheel. According to the firm’s website, Davey and Mulcahey felt that “no one was looking out for those at the center of the healthcare engine: the clinicians on the “front lines” and decided to found Wheel as “the industry’s first model for delivering high-quality virtual care at scale by empowering clinicians and providing new efficiencies for healthcare companies.” According to the company, Wheel helped facilitate 1.3M patient visits in 2021and expects that number to grow by approximately 3-fold by year-end 2022. The Differentiators: Unlike some of its competitors which offer branded virtual care services, Wheel offers a private or “white-label” platform that empowers companies to quickly and easily launch virtual care services on its own by providing them with the appropriate back-end infrastructure and software. In addition, while Wheel is helping traditional healthcare providers like hospitals and physician practices offer virtual primary care services, it is also helping non-traditional players like retailers, pharmacies, and employee benefit programs create their own virtual care programs under their own brand. Wheel claims that using their platform is much more efficient in terms of both time and money than standing up and scaling a virtual care service on your own, which their internal data shows costs an average of $15MM and takes 15 months. Moreover, as we noted in our earlier Scouting Report on Wheel (please see Scouting Report-Wheel: Moving Virtual Primary Care Forward 09/21/21) Wheel has been looking to expand the breadth of its services beyond just virtual primary care for some time and is slated to use some of the proceeds from the round to increase services in labs, and diagnostic care. Interestingly given Wheel’s roots in physician recruitment and staffing, Wheels has a strong background in some of the technical issues involved in scaling a virtual care business. As Davey noted to Forbes about founding the business, one of “the biggest sticking point[s] to scaling digital health startups was understanding the regulations across all 50 states and recruiting licensed clinicians.” Moreover, as noted in our prior article, Wheel continues to experience a strong retention rate of more than 90% even in the face of over 60% growth in its clinician network this past year. Wheel currently has approximately 150 employees (up from 120 in August) and now expects that to increase to 300 by year-end 2022. Wheel charges its customers a base fee for its software and then an additional fee per consultation. The Implications: While Wheel’s last fundraising appeared to be more about the need to keep pace with the explosive growth and market opportunity in digital care created by COVID, this round appears to be more about the transformation to virtual-first care. As CEO Davey noted to MedCity news, in order to move healthcare forward and truly deliver on virtual-first care we need the infrastructure that can deliver “anytime, anywhere” care, which they are helping to create. While the pandemic created a newfound acceptance of digital health, “companies were still struggling to meet their patient’s needs”. However, as Davey notes “the funding puts the company in a strong position to speed the transition from telehealth to virtual first care.” For example, according to the McKinsey 2020 Virtual Care Study “approximately $250B or ~20% of all Medicare, Medicaid, and Commercial outpatient, office, and home health spend, could potentially be virtualized.” Nevertheless, while a great deal of care can be virtualized, virtual first is really about creating a less expensive, more accessible triage point for entry into the system and should begin to enable a true omnichannel experience like consumers experience in most other industries. Davey states, “by leaning on technology, healthcare organizations can more easily triage a patient’s care need and determine the best care setting”. Virtual first brings healthcare much closer to other industries by bringing patient care to the patient at the time and place they desire as opposed to the other way around. Importantly in a time of labor shortages, virtual primary care also provides a mechanism to address the issue of physician burnout, where over 90% of doctors report experiencing at least one symptom of burnout in their lives. By giving them the ability to create their own virtual practice with a much lower infrastructure incidence of burnout can be reduced. While important issues like broadband access and ensuring patients receive culturally relevant care still need to be addressed, virtual first care and technology are changing the nature of healthcare delivery. Wheel Raises $150M in Quest to Move Beyond “telehealth 101” to Virtual-First Care, Wheel Raises $150 Million Series C to Power the Virtual-First Care Revolution, Behind The Screen: Meet The Startup Powering Telehealth