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The Driver: The explosion of growth in telemedicine during the COVID pandemic gave rise to a corresponding increase in demand for additional services like second opinions and e-consults. As increasing amounts of care shifted to virtual delivery, payers soon realized they had to look at managing the costs of specialty care and turned to providers of second opinions and online or e-consults like RubiconMD. Rubicon, which raised an additional $18M in a Series C funding in March 2020 just before the pandemic, has raised $40M to date backed by Deerfield Management Co. and existing investors, Optum Ventures, HLM Venture Partners, Waterline Ventures, and Heritage Provider Network. The Entrepreneurial Insights: When dealing with the underserved, it's incredibly important to understand the cultural and social context of products designed for them. Early on during COVID as virtual healthcare took hold it actually exacerbated health inequities, however, gradually disparities became more broadly recognized and inequalities are slowly being addressed although there is still much more work to be done. The U.S. had a mental health crisis before the pandemic hit and still has a mental health crisis that requires more holistic/integrated care for patients Many healthcare organizations falsely assume that they can’t make money by creating products or services specific to underserved populations. The Story: Founded in 2013 by CEO Gil Addo and President Carlos Reines, RubiconMD enables primary care doctors to electronically consult with specialists in order to determine appropriate treatment protocols, care plans and if needed an in-person appointments with a specialist. One of the company’s primary missions is to eliminate barriers to specialty care given that underresourced patients must often confront the obstacles of transportation costs, time off from work and an inability to determine medical need when evaluating the need for specialty care. We spoke with RubiconMD CEO Gil Addo who stressed their recognition of the urgency of bringing their vision to reality with the onset of the pandemic and the civil unrest shining a light on the existing health care disparities. RubiconMD is currently in operation in 37 States and covers 130 specialties and subspecialties. RubiconMD hires verified specialists who are academic clinicians and well-versed in current practices and methodologies for its second opinions. RubiconMD’s specialists fill in the “second opinion” gap and provide clinicians with the best possible solutions for each case, allowing the PCPs to make the final decision. There are significant costs associated with referring patients to a medical specialist and it has proven to be a barrier for the best standard of care for patients. RubiconMD’s e-consult visit improves patient’s health outcomes, increases satisfaction, and reduces healthcare spending. Moreover, RubiconMD is adding to and reinforcing general practitioners’ knowledge of current practices which boosts confidence when treating patients. RubiconMD has found that patients often do not need an in-person visit with a specialist and can be more effectively treated with continued monitoring and additional follow up care. When necessary they are referred to a specialist. The Differentiator(s): According to Addo, most Rubicon e-consults have a response time of 3 hours since RubiconMD retains over 300 specialists and connects them directly with clinicians. Rubicon’s e-consult platform significantly cuts healthcare costs by avoiding the unnecessary referrals, additional testing and lab services often associated with referrals to specialists as well as proactively reducing ER utilization through early detection and improved care protocols. RubiconMD provides clinicians with the best possible solutions for their complicated cases. It improves patient care by 80% and reduces healthcare spending. Addo was proud to report that a recent claims-based analysis of Rubicon’s e-consults from a national payer-partner over a two year period, found a 50% lower per member per month cost for patients where an e-consult was conducted, which persisted over the entire two year period. Addo has noted that “we are in a major mental health crisis in this country, there is a dramatic lack of supply [of mental health professionals] in this country” and mental health conditions are a major driver of costs in the healthcare system. The Big Picture: The U.S. has one of the highest rates of healthcare expenditure at almost 20% of GDP of which a large portion is often attributed to the practice of defensive/invasive medicine. In addition, the COVID pandemic has highlighted the presence of significant inequities of access to healthcare and disparities in levels of health literacy. RubiconMD is working to shift the narrative by facilitating how medicine can be practiced less defensively and more equitably in the U.S. as the use of telemedicine and virtual care becomes cemented into our healthcare delivery system. Rubicon will also help address the U.S. physician shortage and particularly the scarcity of specialists predicted by the American Association of Medical College predicts to be between 34,000 and 87,000 positions. Rubicon has had great success in expanding access to practitioners in fields such as orthopedics, cardiology, general pediatrics, and more, in underserved and rural areas thereby improving access to convenient high-quality care. RubiconMD has also seen the need to broaden its footprint to include holistic care of a patient’s physical and mental health. Patient’s direct mental health expenditures account for only 5% of healthcare expenditures while those same patients' health related expenditures can account for up to 60% of all healthcare expenses. Finally, given their success in reaching patients impacted by disparities, Rubicon has demonstrated that as noted in the words of CEO Addo, “when dealing with the underserved, it is incredibly important to understand the cultural and social context of products designed for them” not just redesign or repurpose products designed for other populations. RubiconMD Launches COVID-19 Vaccine eConsults and Resources to Improve Access to Latest Vaccine Insights, The Confident Generalist: Putting The Primary Care Physician Back At The Center

Key Takeaways: With increased interdependence of medicine and data sciences, new physician/data scientists are needed to help develop and audit AI models, Most data fed into AI tools tend to be homogeneous patient populations, thus companies must institute frameworks for responsible data use. Minimizing racial and ethnic bias in AI requires auditing both the development and output of models to ensure their clinical accuracy and relevance. Transparency and explainability, particularly around data privacy and security will be key in ensuring trust in models The Problem: AI systems contain biases for many reasons, two very common ones are 1) cognitive biases and 2) incomplete data sets. According to Verywell Mind a cognitive bias is a systematic error in thinking that occurs when people are processing and interpreting information in the world around them and affects the decisions and judgments that they make. Cognitive bias often works as rules of thumb that help you make sense of the world and reach decisions with relative speed. They may manifest themselves as feelings towards a person or a group based on their perceived group membership. More than 180 human biases have been defined and classified by psychologists, and each can affect individuals for whom we make decisions. These biases could seep into machine learning algorithms through developers unknowingly introducing them to the model or a training data set which includes those biases. Data completeness refers to “a structured and documented process performed to ensure that any database is complete for its intended use” and that all of the data needed is included and available. In addition, in healthcare, “data are considered complete if a patient record contains all desired types of data (i.e., breadth), contains a specified number or frequency of data points over time (i.e., density), or has sufficient information to predict an outcome of interest (i.e., predictive)”. However given the inequalities in access to healthcare for some underserved communities, data will often be incomplete. According to a 2020 study entitled, Ethics of Big Data and Artificial Intelligence in Medicine, “most data fed into AI tools tend to be homogeneous regarding patients’ characteristics. This may result in an under-representation or an over-representation of certain groups in the population”. For example, according to the COVID Racial Data Tracker, while Blacks accounted for over 15% of COVID deaths, they made up less than 10% of the population for clinical trial participants for both the Pfizer and Moderna vaccines. If the data available for AI is gathered primarily from a White population, the resulting AI systems will know less about other populations and therefore will not benefit Black patients or patients from other ethnic groups, per se. As noted in Ethics of Big Data and Artificial Intelligence in Medicine, “common practice is that minority populations are often under-represented, which makes them vulnerable to erroneous diagnosis or faulty treatment procedures as a result”. The Backdrop: Applying AI to clinical issues in healthcare is difficult. Healthcare data can be unstructured with data privacy and security issues further complicating data sharing. In addition, as we have seen during the COVID pandemic for a variety of reasons, underserved populations are underrepresented in training data sets and these data sets themselves contain elements of conscious and unconscious bias. As noted in Algorithms, Machines and Medicine in The Lancet “ training only on patients from one health service or region...runs the risk of overfitting to the training data, resulting in brittle degraded performance in other settings.” Data scientists and clinicians may approach data through a different lens. For example data scientists may seek to optimize models without considering the ability of clinicians to impact the variables they are trying to optimize. On the other hand, physicians often struggle with the balance between application of their clinical experience and trusting treatment protocols derived from technologically complex, often unexplainable AI tools. Along those lines, patients and clinicians want to understand the factors that went into data driven models, what factors these models consider, how these models arrive at their conclusions and how clinically valid treatment protocols derived from these models are. If nothing else, patients want to be assured that they will not be harmed in any way by following the advice of AI derived models. Implications: As we merge medicine and data sciences together, we must keep equity, transparency, explainability and trust in the forefront; these suggestions on eliminating biases in AI are crucial. AI and machine learning tools are products of the human mind and human beings inherently carry biases and by proxy their products/creations are prone to contain many of these same biases. As the novel pandemic exposed the existing disparities within the healthcare systems, efforts must be made to consciously assess models to ensure that they do not contain bias both conscious and unconscious going forward. First and foremost data scientists should ensure that data and data training sets collected for research and treatment must be heterogeneous enough to build deep learning algorithms that represent the diverse patient populations they are meant to serve. This will help ensure historically marginalized groups are treated fairly and accounted for in the algorithm development process to improve health outcomes. As outlined in Enhancing Trust in Artificial Intelligence: Audits and Explanations Can Help, “companies [should institute] a framework for responsible data use, particularly in the context of avoiding bias”. In addition, greater formal collaboration between physicians and data scientists is required to ensure that models are looking at the appropriate data and impacting treatment plans correctly. In fact, a number of programs including the Cleveland Clinic’s Center for Artificial Intelligence (CCAI) and Inception Labs at the Medical College of Wisconsin are pursuing interdisciplinary training and development to improve the application of AI initiatives in healthcare. Audits should also become a consistent and required part of the AI development process. As noted in a 2018 report from the Information Systems Audit & Control Association (ISACA), audits “should focus on the controls and governance structures that are in place and determine that they are operating effectively”. Audits should occur both pre-development and post-training/prior to implementation to guarantee that models do not have disparate impact, that they follow all existing laws and regulations as well as following all best practices. One approach may be to evaluate and map all such models for any potential disclosures of Protected Health Information (PHI). Data scientists and clinicians must take steps to ensure models are transparent and explainable to gain the trust of patients and clinicians. This must include explaining the factors that go into building models including demographic data, the nature and types of training data and parameters the models are trying to optimize. In addition, to the extent possible, developers of AI models in healthcare must be able to provide answers to patients’ questions surrounding data privacy and security including the availability and exchange of data. “Patients must have the right to decide: who will own their data, where that data will be stored, and what that data will be used for.” These suggestions coupled with incorporating evolving metrics for ‘fairness’ and equity are non-negotiable for improving overall health outcomes. Ultimately, by correctly combining the processing capability of artificial intelligence with the experience and insights gained from the human minds, healthcare systems can improve the quality of care, drive better patient outcomes and reduce burden on the healthcare system. Related Reading: Ethics of Big Data and Artificial Intelligence in Medicine Enhancing Trust in Artificial Intelligence: Audits and Explanations Can Help Auditing Artificial Intelligence Bias in AI: What it is, Types & Examples of Bias & Tools to fix it Tomorrow's Doctors Seek Training in Data Science, but Will That Be Enough?

The Driver: One of the many things demonstrated by the COVID pandemic was the need for improved care coordination, record keeping, and collaboration in the care of seniors. In addition, since caregivers and families were unable to visit patients due to the pandemic, seniors became socially isolated, taking a toll on their physical and emotional health. As a result of the devastating impact of COVID in senior care facilities, many have looked to examine their entire systems and models of care, looking to leverage technology to improve care and solve for workforce shortages post-pandemic. The Takeaways: Lack of communication between families and clinicians/senior care personnel often creates unwarranted friction and mistrust early on in the relationship. Interoperability in data sharing is key for healthcare, however, poor charting and high employee turnover rates are major obstacles in care delivery and diagnostics for seniors. A comprehensive EHR can seamlessly integrate quality and personalized care, facilitate care transparency, maintain compliance with regulations and reduce medical errors. Incoming senior residents are going to be more familiar with technology and there is an opportunity to invest in a technologically-capable approach when providing care for senior residents. The Story: Caremerge was founded in 2015 by Fahad Ahiz, who was originally seeking to create a “Facebook for seniors” but soon realized there was a broader need for communication and collaboration that included connecting senior care facilities and families/caregivers. Azix, now the company’s chief technology officer, soon realized there was a large, untapped market in leveraging technology to strengthen care coordination to improve the quality of life for senior residents and their families. Caremerge realized early on that applying technology could not only help free up caregiver’s time but also fosters patient satisfaction and by boosting communication of providers with patients and families. To date, the company has raised over $25M, most recently completing a Series D financing in July of 2019 raising an additional $5.2M from Echo Ventures, Ziegler and other undisclosed investors according to PitchBook. The Differentiator(s): Early on Caremerge realized they could leverage technology not just to improve communication and collaboration but to help improve care and reduce costs. By continuing to seek ways to apply digital tools to senior care, Caremerge has reported positive health outcomes and a decline in healthcare costs. Breaking down the overall communication scheme into three main parts has essentially allowed for a multi-faceted care coordination approach. Starting with pre-admission profile building, moving to involving the family and managing expectations and finally, synchronizing wellness and clinical efforts, the overarching care coordination system allows for innovative ways to monitor and improve the patient’s health. For example, Aziz noted that the company realized they could leverage artificial intelligence technology not only to improve communication but to analyze a patient’s condition. By “anticipating” such things as falls they could then apply AI to help avoid them. In addition, in senior care facilities recording keeping is still paper based, manual and difficult to share. In addition, Aziz noted that senior facilities often have high turnover rates and patients often have interactions with providers, outside facilities like hospitals, and physician groups. Consequently, Caremerge had looked to deploy EMR technology within senior care facilities to allow for more robust communication. An article in Electronic Health Reporter noted, “a centralized and digitized record of contacts invites everyone to the conversation about a resident’s health”, improving care and patient/family satisfaction. Their forward thinking has allowed for creative solutions like “Caremerge Voice”(with Amazon’s Alexa) and “Calendar Central”. These solutions improve overall communication and programming events between departments, patients and their families, and the care teams. The Big Picture: As demonstrated by the COVID pandemic, families and caregivers of residents in senior care facilities are an important component of the care team, often helping to advocate for patients and relieve stress on overburdened staff. In addition, social isolation is proven to have a detrimental impact on the physical and mental health of residents. Maintaining ties for seniors can be crucial for improving their care and well being. Tools like Caremerge, which help keep families and caregivers involved and informed, can simultaneously improve quality and lower costs for providers. In addition, Caremerge demonstrates how technology such as AI can be used to enhance care and allow for more human-based care delivery when providers are not tasked with mundane administrative duties. Caremerge helps healthcare providers improve accuracy in data collecting, develop a better longitudinal care record and ensure better care delivery and diagnostics. However, current EHR and electronic Medication Administration Record technology (which automatically documents the administration of medication into certified EHRs) are lacking. The industry also suffers from poor handoffs of patients between facilities and providers, improper data recording (due to variations in training), and incomplete health records which can often lead to or contribute to poor health outcomes. Integrating families into the patient’s care plan, improved documentation and enhanced interoperability through Caremerge can enhance a patient's health outcomes and wellbeing. Technology with the Human Touch EHR Integration Is Key To Running a Five-Star Senior Healthcare Facility

Our Take: The COVID-19 pandemic has increased the use of telehealth and medical technology as federal restrictions were loosened and waivers were put into place. Although telehealth is used more frequently to treat acute conditions, physicians need to be wary of the potential for malpractice issues in the future. There are outstanding concerns around whether providers are aware of particular guidelines to ensure the standard of care has been met. Post pandemic, waivers will be lifted, in-person medicine will likely return closer to pre-pandemic levels and limits could be placed on practice guidelines posing a risk to providers practices. Key takeaways: ● The Federal Government’s decision to expand services covered by telehealth included removing licensing restrictions and extending coverage to Medicare patients. ● The retightening of telehealth regulations could result in providers being held liable for breaching the standard of care if patients are harmed during telehealth visits if providers don’t remain on top of regulatory changes. ● Telehealth significantly reduced the barriers to telehealth utilization but placed significant concerns on how providers can practice safely and within their jurisdiction in the future. ● In response to concerns providers face, there are at least four preventive steps providers can take to avoid malpractice claims. The Problem: As telehealth use increases with the greater acceptance by patients and providers for care following the pandemic, and the increasing potential to use it for higher acuity cases there are concerns about the potential for higher incidence of telehealth malpractice claims. In particular, two areas of concern center around providers’ ability to adhere to data privacy and security regulations and the potential for misdiagnosed conditions. While state and Federal regulators waived a number of regulations around data privacy and security during COVID, once the public health emergency ends, there are questions about whether providers will be able to ensure full adherence to federal privacy and security rules. Given the increased number of platforms and methodologies by which patients participated in telehealth during the pandemic (including non-HIPAA compliant textng and video-chat) more opportunities will present themselves for intentional and non-intentional violations of the Health Insurance Portability and Accountability Act (HIPAA) and the California Consumer Privacy Act (CCPA). With regard to misdiagnosis, while the pandemic moved patients towards greater use of telehealth, some remain skeptical that telehealth can effectively diagnose and treat patients particularly as it moves to treat higher-acuity conditions. For example, misdiagnosis may occur due to ineffective communication, an inability to establish a robust physician-patient relationship, or providers being unable to get a complete and detailed patient history. In addition, given the lack of an in-person physical examination there is also the potential that providers may miss non-verbal clues more easily picked up in a physical examination. The Backdrop: Many years prior to the pandemic, in 2005, The Public Readiness and Emergency Preparedness Act (PREP Act) authorized the Secretary of the Department of Health and Human Services (HHS) to make certain emergency declarations providing immunity from liability to aid in addressing a public health emergency (PHE). In January 2020, President Trump declared a PHE allowing the HHS to institute certain emergency measures. Following the declaration Federal and state regulators eliminated or suspended barriers to implementing digital health, resulting in dramatically increased usage. According to a study by the American Medical Association (AMA), the Federal Government’s decision to ease provider privacy requirements, expand services coverable by telehealth, remove licensing fees restrictions, and extend telehealth coverage to all Medicare via the increase in covered services significantly reduced the barriers to telehealth utilization. Among some of the policy changes implemented were: 1) allowing physicians to provide telehealth services to out-of-state Medicare beneficiaries, 2) relaxing strict enforcement of fines for non-compliance with HIPAA rules, 3) paying providers the same rate for telehealth services as in-person visits for Medicare patients, and 4) $200 million in increased funding from the Federal Communications Commission (FCC) under the CARES Act to support eligible health care providers in obtaining the necessary devices to facilitate the provision of telehealth services. Despite this loosening of regulations during the pandemic, a recent article in Becker’s Hospital Review pointed out that there are a number of potential medical malpractice concerns providers should be aware of when delivering telehealth services. The article, which cited the Wolfe Pincavage law, noted that telehealth malpractice concerns center around five areas including: 1) data breaches of patient’s protected health information, 2) misdiagnosis or possible improper prescription of patient’s medications 3) software limitations and/or internet glitches that may lead to diagnostic errors, 4) accurate documentation by providers which ensures patient confidentiality and standards of care are met, and 5) providers being significantly well versed in their respective states telemedicine laws to ensure they are meeting all of the specific requirements of state law. Telehealth delivery exacerbates the concerns providers may face, which can hold them liable for breaching the standard of care if patients are harmed as a result of incomplete or inadequate care during telehealth visits. Implications: The COVID-19 pandemic completely changed the outlook on telehealth services and how care is delivered. While traditional approaches to seeking medical advice were effective, telehealth provided added convenience and flexibility, particularly for people who were afraid of exposing themselves to the Coronavirus during the pandemic and did not want to visit medical facilities, like hospitals. In addition, telemedicine can broaden healthcare access by allowing patients in remote areas to access care where care options may be limited. Nevertheless, telemedicine poses its own unique set of risks and challenges compared to the in-person practice of medicine. For example, due to state and Federal laws there are unique requirements regarding jurisdiction, procedure, and duty of care. In addition, given that numerous legislative and regulatory changes are expected as the waivers during the PHE end, providers and clinicians must ensure they remain diligent in following rule changes to ensure their practice does not exceed the scope of their medical licenses as telemedicine often crosses state lines. Also, while telehealth usage has declined sharply from the peaks seen during COVID, overall utilization levels are expected to remain higher than pre-pandemic levels as is the level of acuity of conditions treated via telemedicine. As a result, the potential for malpractice issues is likely to be greater in the future. As noted in a recent article entitled “Is the Doctor In? Medical Malpractice Issues in the Age of Telemedicine” providers can take four steps to help avoid malpractice: 1) be vigilant and ensure effective telehealth visits, 2) be more cautious with consent and proper documentation prior to the telehealth visit, 3) ensure the technology used for telehealth visit comply with HIPAA, HITECH and state regulations and providers abide by all in-person medical practice standards, medical licensing boards, and 4) seek advice from their legal departments to better understand potential liabilities as there may be certain medical malpractice risks towards telehealth as compared to in-person care. As telemedicine becomes a more consistent part of the mutli-channel care delivery model, providers will want to ensure successful telehealth encounters as demand increases. Similarly, they will want to ensure strict adherence to state regulatory mandates, including regular checks with counsel and routine audits to reduce the risk of licensure violations and malpractice liability. The successful adoption and usage of telehealth and adherence to the prevailing regulatory standards will ensure their practices remain on the cutting edge of healthcare delivery in order to increase the role of preventive care, lower hospitalization rates and decrease healthcare costs. Related Reading: 6 Things to Know About Telehealth Medical Malpractice Concerns Uptick in Telehealth Reveals Medical Malpractice Concerns Is the Doctor In? Medical Malpractice Issues in the Age of Telemedicine CARES Act: AMA COVID-19 Pandemic Telehealth Fact Sheet

The Driver: Adyn, a Seattle startup, raised a $2.5 million seed round co-led by Lux Capital and M13. Adyn plans to use the funds to launch its birth control optimization test later this year. It has already sparked demand and has a waiting list for users. The Takeaways: Adyn’s at-home kit measures hormone baseline levels and assesses genetic risk for two of the most serious birth control side-effects: depression & blood clots Women’s health is often understudied, resulting in medically unexplained symptoms according to a report in Cogent Psychology. Women are more commonly misdiagnosed than men due to the medical research gap per the Association of Health Care Journalists. The Story: Adyn’s co-founder, Dr. Elizabeth Russo came up with the idea when she encountered side-effects of changing her birth control medication and “was thrown into suicidal ideation”. Given her background as a Ph.D. in genetics and genomics, Ruzzo was able to recognize this was due to the change in medication. However, as a result of the experience, she became dedicated to defining how gender gaps in research can lead to differences in disease and drug response particularly with birth control medications. For example, the company notes that over 50% of women try four or more birth control medications before finding one that works for them. Following her experience, Ruzzo launched a platform to address health disparities in women’s health while improving health literacy for her clients. Adyn’s mission is to close the medical research gap in women’s reproductive health. The Differentiator(s): While there are platforms that offer birth control without a doctor’s prescription, Adyn is attempting to change healthcare diagnostics and delivery through its telemedicine platform by using precision medicine to better match patients with accurate birth control prescriptions that attempts to minimize side effects. For example, while there are over 200 birth control contraceptives on the market they are generally prescribed for specific patients without any kind genomic testing for side effects, etc. (not to be confused with side effects and efficacy testing during the approval process) . Since the 1960s, birth control users have generally gone through a process of trial and error with multiple birth control prescriptions before finding one that works for them. For example, according to an article in Business Insider the “average time spent on contraceptive counseling is 12.9 minutes” and both patients and providers have become accustomed to this unscientific method when it comes to finding the best birth control. Due to gender and racial gaps in medical research, the pill selection process remains shrouded in mystery and frustration resulting in a broad range of reported side effects. These can range from weight gain to blood clots to depression when the patient and provider’s actual goal would be to have birth control be side effect free. Adyn’s telemedicine platform is equipped with specialized birth control specialists who aid in the pill selection process after testing and reviewing a patient's history. Adyn’s optimized at-home test collects information about an individual’s hormone level (through multiple readings) and genetic risk (via a single reading). These results are then explained to the patient, providing them access to their own biological data to help them make the decision in a comprehensive manner. Adyn is aiming to improve both the diagnostic approach and delivery of birth control contraceptives, and Adyn expects to offer reproductive healthcare recommendations (family planning, fertility, birth control) through their trained specialists. The Big Picture: For the past 30 years, women have generally been using an opaque process when choosing their birth control and certainly not one as scientific as many would expect given the wide range and severity of potential side effects. By closely monitoring and pairing birth control users with contraceptives that have minimal side effects, women's daily life and reproductive health should be improved. Through feedback and surveys with their patients, Adyn will also have the opportunity to investigate other reproductive problems such as polycystic ovary syndrome (PCOS) is a hormonal disorder common among women of reproductive age than can cause infrequent or prolonged menstrual as well as other menstrual irregularities. Lastly, by rejecting the outdated ‘trial and error’ method for birth control selection, Adyn can help demonstrate the quality and effectiveness benefits of personalized medicine and genomics on a broad scale which is likely to shape healthcare delivery well into the future. Precision Medicine Company Adyn Raises $2.5M Seed Funding for Personalized Birth Control

Our Take: Community pharmacists (CPs) can help alleviate the healthcare burden and close healthcare access gaps since getting care from pharmacists is more convenient and cheaper for patients. For example, the Canadian healthcare system uses community pharmacists to help treat uncomplicated urinary tract infections (UTIs) which affect more than 50% of women before the age of 32 and which requires a simple round of antibiotics prescribed on time. Formal cost-effectiveness studies indicate that CPs are a viable and effective treatment option, providing readily accessible, and quick care that reduces the burden placed on other healthcare services and professionals. Key Takeaways: Publicly funding community pharmacists is beneficial from a societal and patient standpoint Community pharmacists can provide certain types of care and medication management more cost-effectively than PCP for certain chronic and routine conditions Patients prefer receiving acute care from their pharmacists due to convenient, quick and safe access to care In many cases, community pharmacists are often more trusted and better situated to improve a patient’s health literacy than PCPs The Problem: When prescriptions are required for certain basic conditions they may often be accompanied by additional layers between the prescriber and patient that may result in additional inconvenience and deter patients from filling their prescriptions. For some just the actual act of having to schedule an appointment with a primary care physician can be very difficult and time consuming. For example, according to the American Pharmacists Association, patients can wait 28-34 days before seeing a healthcare provider. In addition, given the shortages of primary care providers, particularly for those who may lack health insurance or be on Medicaid, wait times may be even longer than that. Patients may also lack the appropriate technological access or literacy to avail themselves of online scheduling or administrative tools which may delay their ability to get appointments or access the appropriate paperwork. Depending upon the nature, severity or symptoms of the condition, the wait times for the appointment itself can end up jeopardizing patients health. Additionally, where patients do not have insurance coverage, it may cause them to delay or forgo care because of cost which often means waiting until conditions become more severe and problematic. Similarly, for patients in certain socio-economic groups, getting access to transportation and having to take time off from work or other care-taking responsibilities presents a practical burden that dissuades them from getting care in a prompt or timely fashion. For a number of years, policy makers have looked to advance practice pharmacists or community pharmacists to help alleviate some of these issues. As noted by the Surgeon General in 2011, pharmacists are uniquely positioned (through their accessibility, expertise and experience) to play a much larger patient care role in the U.S. health care delivery system to meet demands and improve the health of the nation. While a number of states have instituted additional designations and require additional training, this solution is still not being applied broadly enough. The Backdrop: For certain more routine or chronic conditions seeking care directly from a CP allows patients to skip the inconveniences of primary care appointments and logistics of getting prescriptions filled. In recent years, the pharmacist’s role has evolved to include the ability to prescribe certain types of medications, adjust and monitor drug therapy and perform patient assessments. Pharmacists routinely provide educational consultations, help manage chronic conditions, assist in the coordination of care and help provide health and wellness services. CPs broaden access to care by providing patients with a number of more convenient and easily accessible options and since they work in local communities, they are available on a more flexible schedule often giving patients a variety of access options (nights, weekends, in-store, at local clinics, without appointments, etc.). For example, according to the Journal of the American Pharmacists Association, 95% of the U.S. population lives within 5 miles of a pharmacy. More recently, a larger number of states are allowing pharmacists to take on broader responsibilities and 4 states have created “advanced practice pharmacist designations” (California, Montana, North Carolina and New Mexico). In addition, currently all 50 states allow pharmacists to furnish naloxone for opioid overdoses while 7 states allow pharmacists to prescribe smoking cessation products, and 2 states allow pharmacists to dispense pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP) for HIV prevention without a doctor’s prescription. Implications: Uninsured Americans remain in a healthcare dilemma. The inability to secure a healthcare plan impedes their ability to get appropriate timely care often resulting in them seeking it through the emergency department and after a condition has worsened due to lack of treatment. CPs are a cost effective, patient-focused way to overcome the barrier of access and provide care that is better situated to the patient. Given their existing relationships, frequent contact with patients, their existing place in the community and their natural role as a source of healthcare information, CPs can increase access to primary care services, help control costs, and improve outcomes for chronic and more routine conditions, such as: asthma, UTI, or arthritis. As noted above CPs were proven to be an effective mechanism for improving UTI care. From a societal standpoint, publicly funded CPs were projected to save over $37.3 million CAD (approximately $30M USD) in 5 years just for UTI treatment and care management alone. Given their proximity to patients and the frequency of interactions (pharmacists have a greater number of visits per year than either primary care or outpatient hospital visits), CPs can also be effective at reaching underserved populations. For example, statin prescriptions are often lower in underserved populations despite a high incidence of conditions such as diabetes which would indicate they are warranted. A study of statin use in diabetic patients from the National Health and Nutrition Examination Survey (NHANES) found that women and blacks diagnosed with diabetes were less likely to receive statin therapy than men and whites respectively. The study’s authors concluded that “the study demonstrated successful implementation of a targeted medication initiative by pharmacists to improve statin prescribing rates.” In addition, CPs could be quite valuable in reducing medication errors and improving care when a patient transitions between care settings. It is estimated that 60% of medication errors occur during transitions of care which likely could be reduced through the use of CPs. While there are issues of liability and reimbursement that must be addressed, clearly making greater use of pharmacist skills and community connections could improve the quality and access to care. Related Reading: Advancing Pharmacist Prescribing Privileges: Is It Time? Community-Based Pharmacy Practice Innovation and the Role of the Community-Based Pharmacist Practitioner in the United States Pharmacist Statin Prescribing Initiative in Diabetic Patients at an Internal Medicine Resident Clinic Prescribing Authority for Pharmacists: Rules and Regulations by State

The Driver: On March 31, 2021, CirrusMD raised $20 million in Series C funding and is set to grow and expand their mission of bringing physician-directed virtual care services via a telehealth messaging platform; connecting patients directly to a real doctor in less than 30 seconds. Securing a VA contract and including telemental health services (with a continuity based healthcare plan), CirrusMD is quickly answering the surge in demand for telehealth services at a competitive price point. The firm’s latest round of fundraising was led by Blue Venture Fund, with participation from 7wireVentures, Drive Capital and the Colorado Impact Fund bringing the total funding to $45 million according to PitchBook. The Entrepreneurial Insights: Changing healthcare is a very slow process for a good reason, if you break something in healthcare then people get broken. In healthcare you want to be a camel (not a unicorn). You need to be ready to go long distances with very little water. Entrepreneurs need to favor intelligent design over show of hands. Intelligent design is more important than user testing/feedback etc. Be ready for the entrepreneur dilemma: am I on the right track or is this not being executed properly? The Story: CirrusMD, co-founded by Blake McKinney, an Emergency Room (ER) physician. We spoke with Blake McKinney, MD co-founder and President of CirrusMD to get his perspective on the company and the company's growth trajectory going forward. He stated the idea for the company was crystalized when as an ER doctor he noticed that patients were experiencing long wait times which resulted in frustration and communication gaps. The large majority of these were situations where patients didn’t need to go to the ER or were in the ER only because they could not get the correct treatment earlier. Overall he was seeing preventable issues, which ultimately resulted in patients being treated at a high cost site or for a preventable condition putting an increased burden on healthcare services and professionals. Dr. McKinney also noticed that many patients do not have access to a medicinal expert in their inner circles and aren’t able to distinguish whether their problem requires an actual ER visit or a visit with a primary care physician. Colorado-based start-up, CirrusMD, is a telemedicine platform that uses text messaging to allow patients to directly text a doctor to determine if ER services are necessary. CirrusMD eliminates the concept of a virtual “waiting room” altogether because they quickly connect a patient to their doctor within 30 seconds (and are contractually committed to responding to patients in under 60 seconds). This automatically boosts patient satisfaction, eliminates unnecessary ER visits (driving down healthcare costs and associated costs). More importantly, patients are subjected to timely care and treatment; improving health outcomes overall. According to McKinney primary care volumes are currently up 200% year-over-year mental health volumes are up 300% year-over-year with revenues currently doubling year-over. The Differentiator(s): Since texting is asynchronous, CirrusMD doctors can effectively handle 10-12 patient encounters per hour (vs. 3-4 for synchronous video or telephone visits) allowing CirrusMD doctors to efficiently manage much higher patient volumes. While the large majority of visits are resolved by text, the CirrusMD does have the ability to handle video telemedicine visits, though that happens less than 5% of the time and tends to be where state laws mandate a video visit for it to be counted as a telemedicine visit. McKinney also noted that texting can be a very effective diagnostic tool as doctors can come 85% closer to the patients’ diagnosis just by listening to the patients through text (before touching the patient or taking clinical assessments). He noted that “it is not about severity every time, often it is about promptness” optimizing text messaging is a way to immediately begin diagnosis and care delivery thus facilitating quicker treatment. For example, text compares quite favorably with patients visiting an actual ER doctor at a brick-and-mortar facility where patients often spend hours waiting before actually being seen and eventually diagnosed. In addition, McKinney stated that CirrusMD had specifically rejected the idea of online waiting rooms as they can cause frustration for patients and negatively impact the patient-physician encounter. Similarly, he felt that the industry had done itself a disservice by employing chat bots to triage patients as it creates a negative experience for patients and can impact the patients level of trust in the care they are receiving. Importantly, while some studies have indicated that telemedicine and virtual care can actually increase the cost of care by requiring in-person follow up visits, CirrusMD reports that their resolution rate is at 83%, meaning that patients who have seen a CirrusMD clinician do not touch a brick and mortar physician within 14 days. The Big Picture: CirrusMD is a true telehealth platform that demonstrates the efficiency for both patients and providers of asynchronous care. For example, McKinney noted that Target Corp. was a client and his doctors will often have visits initiated by employees at their convenience, like while they are on breaks or other times that would not be conducive to scheduling video or telephone. Examples like these showcase a value-based approach to healthcare that can allow for best practices (convenient easy-access, rapid attention to an issue when it first presents resulting in more appropriate, lower cost of care). Moreover, by allowing patients to chat with a doctor at home or work on their own terms, visits to high fixed cost facilities can be eliminated, as can the burden of transportation and time away from other responsibilities. Not only does this result in happier and healthier patients, ultimately this leads to doctors reporting higher levels of job satisfaction as well as spending more time on direct patient care and less on administrative tasks. CirrusMD Announces $20 Million in Series C Funding; Telemedicine Startup CirrusMD Raises $15 Million to Connect Patients with Doctors

Our take: Wearable technologies will transform patient care from episodic to longitudinal by bringing empowering innovative solutions that provide more continuous care insights as well as more convenient and frequent transfer of information between patients and providers. As a result, patients will receive higher quality, lower cost care. For example, given advances in technology, wearable sensors paired with advanced algorithms can now be used to predict a range of conditions including the onset of infections, inflammation, and even insulin resistance by monitoring vital signs such as heart rate, physical activity and skin temperature. Wearables provide an easy to use and convenient way for consumers to monitor their own health and eliminate the need for preplanned actions by patients such as finger-pricking or manually entering data in records. As a result, users can seamlessly monitor their health data via an app connected to the wearable and tailor the use to themselves and their lifestyle. Wearables have an expected annual growth of 30% globally and are forecasted to generate roughly $67 billion by 2030. Nevertheless, there are still issues surrounding access to wearables, such as broadband access, education, cost, safety, and data privacy/security. Key takeaways: Wearable technologies will: Work to improve health outcomes and provide cost-effective solutions Increase patient self-awareness and engagement allowing people to monitor their health more conveniently Allow health information to be shared more fluidly with providers, enabling early detection and prevention of diseases while maintaining health Potentially lower hospital costs by as much as 16% in the next 5 years The Problem: As noted in Nanoelectronics Materials, Devices, Applications, “originally designed for acute, episodic care rather than ongoing treatment of chronic conditions, the current health systems are not good at providing the ongoing, coordinated care required by the latter.” They add that since “the large majority of diseases are linked to chronic disease” integrating coordinated care with health systems will be key particularly as the number of patients in the 65 or older category increases as a percent of the population. The Backdrop: Wearable consumer healthcare devices have been around for over a decade. Fitibit invented its first step counter in 2010. Since that time the market for wearable technology and smartwatches has exploded. For example, according to a Pew Research Center study conducted in June 2019, roughly one in five adults regularly wear a smartwatch or wearable fitness tracker. The global market for healthcare wearable devices is expected to grow at an annual growth rate of 30%. The growth is expected up to $27 billion powered by smartwatches. These technologies are designed to both empower and engage patients by allowing them to capture data about their behaviors that lets them monitor their daily health and share their health information with providers. Moreover by providing timely and accurate feedback these devices can educate patients as well as empower them to take corrective action when misperceptions exist (ex: amount of daily exercise) thereby facilitating disease prevention and maintenance of health. Health data collected by wearables can be categorized into either ‘quantified self’ (QS) or wearable technologies. Wearable technologies typically automates data collection and uses an algorithm to analyze the data it collects and then presents recommendations based on the data. Quantified selfers apply the unanalyzed personal numeric data collected from the wearables to activities such as eating, sleeping, and exercising which the user can then use as motivation to potentially drive behavior change. Wearables are embraced by users because they are an automated way to track certain data as long as the user is wearing or carrying the device. Wearable technology ranges from smart-watches to smart fabrics. The most commonly measured data include vital signs (heart rate, blood pressure, body temperature, blood oxygen saturation), posture and heart health via an electrocardiogram. From those first step trackers, wearables have now evolved to include: 1) smart glasses for monitoring electrical impulses in the wearer’s brain while tracking eye movements, 2) necklaces for heart monitoring, 3) contact lenses to track glucose levels or eye pressure, 4) headbands to capture electroencephalograms, and 5) apparel embedded with technology that allows cardiac measurements. These wearable technologies can directly impact clinical decision-making as they allow real-time measurement and diagnosis of issues that can facilitate timely interventions. In addition, since the measurements are continuous and longitudinal instead of episodic, patients can get better, more precise care while reducing the cost of care (ex: patient monitoring and rehabilitation outside of hospitals). According to “Wearable Technology Applications in Healthcare: A Literature Review” wearables are currently being used in: 1) prevention and maintenance of health including fall detection, physical activity monitoring, stress detection and weight control; 2) patient management using point-of-care diagnostic devices; and 3) disease management including cardiac monitoring, blood pressure monitoring and, diabetes care management, just to name a few. While the technology is still in its early stages and there is debate about the usefulness of consumer vs. medical grade wearable technology for clinicians, as the quality of the technology improves this gap should narrow considerably. Nanoelectronics Materials, Devices, Applications notes “by combining the convenience and frictionless use of consumer wearables, the signal quality of medical-grade physiological sensors and the personalized algorithms to adhere to coaching, powerful solutions will emerge that would assist our health at any age.” In addition, a number of studies have demonstrated that while consumer wearables may not be as accurate as medical-grade technology there is a correlation between their measurements and those taken with medical-grade technology. Implications: The integration of wearable technologies provides innovative solutions for combating healthcare issues since they are designed to maintain health by continuously monitoring conditions and enabling disease prevention. Not only can they provide real-time, early indications of adverse health situations, wearable technologies can reduce costs by helping diagnose and treat conditions before they become acute and often can receive care without the expense of visiting a hospital or other facility. According to Forbes, wearables are projected to lower hospital costs by as much as 16% over the next five years. These technologies provide convenient and cost-effective access to those seeking care. In addition, wearables can allow at-risk patient populations to be monitored more closely and become more actively engaged with their health, thus accelerating and improving health outcomes. Although there are many positive aspects to utilizing wearables technologies, we must recognize that they are still in the early stages of achieving their potential. Issues such as user acceptance, data privacy and security, and ethical applications may impact accessibility and acceptance. Ensuring patient confidentiality and data security while complying with HIPAA regulations through devices such as encryption and authentication will be vital to ensure that data is trusted, and secure. Patient compliance and adherence will also weigh heavily in the success of wearables with patients being the key ingredient in the application. Therefore, user interface and user experience must be tantamount in the design of the wearable products and their accompanying applications. Well designed wearables should encourage patients to actively address the role their behavior plays in their health and take responsibility for their lifestyle choices. For example, according to a study by HIMSS entitled, Wearable Technology Applications in Healthcare: A Literature Review”, user preferences need to be considered in the design of devices in order to gain clinical acceptance and be useful within typical user settings for patients. Wearable devices should be compact, simple to operate and maintain and not affect a user’s daily behavior. Similarly, healthcare providers must ensure that patients are comfortable enough in their clinical relationships that they will be compliant in their use of the technology and well-versed in operating it to achieve successful use. Moreover, the more individual patients use wearable devices, the better artificial intelligence and machine learning algorithms will be at collecting and discerning patterns collected from their behavior and recommending personalized interventions to improve their care and health. Importantly, when used to their fullest potential, wearables will not be replacing healthcare professionals, but rather will act as an adjunct to clinicians to make it easier to manage health outcomes and provide insights, particularly for those who may lack access to clinicians or need more continuous monitoring. Related Reading: Wearable Health Technologies And Their Impact On The Health Industry Wearable Technology Applications in Healthcare: A Literature Review Increasing Patient Engagement Through the Use of Wearable Technology Healthcare Wearable Devices: an Analysis of Key Factors for Continuous Use Intention

The Driver: In late March Crossover Health raised $168M in a Series D round to expand it’s employer-based primary care model, including a recently announced agreement to expand its partnership to build primary care clinics for Amazon workers. According to the company the funds will be used to expand their data intensive “Connected System of Health” across the U.S. and to build out centers for the Amazon partnership. The Entrepreneurial Insights: Founders must be willing to take a step even if they can’t see a clear outcome...you can’t sit around and wait for inspiration, the inspiration comes from putting the work in You must have a clear vision and build towards that. Healthcare is very difficult and it will outlast you. You can’t be impatient and think everything will turn in two years, there are too many twists in the road. We realized from day one that our model had to work outside the [existing] system. We knew we didn’t want to be fee-for-service and we were going to go all in on that. Today’s world is focused on instant fixes, you must have a long-term vision, don’t get distracted by what is cheap, convenient or easy. Outlast the noise, outlast the rumor and have enough conviction to stay with it...you can affect lives. The Story: Founded in 2010, Crossover Health provides an integrated care model primarily for self-funded employers including Apple, LinkedIn, Comcast, Amazon and others. Crossover’s model which began with on-site clinics and now includes virtual care, behavioral health, health coaching and patient navigation which the company refers to as Primary Health. The company has approximately 400K lives under management served by 48 in-person health centers in 11 states. In addition, the company delivers care virtually in all 50 states. In July 2020 Crossover announced a partnership with Amazon to build clinics for Amazon employees, near fulfillment and operations centers and the partnership has since been expanded to a total of 20 clinics. The company claims to save their clients approximately 15% on average by emphasizing coordinated primary care. Unlike other models where patients just have a single primary care physician (PCP) , Crossover patients are assigned to a dedicated collaborative care team which has the ability to share patient data. Crossover patients can choose on-site or virtual care and can connect with care providers via synchronous or asynchronous options which according to Crossover CEO Scott Shreeve allows them to build deeper relationships with their patients whereby they “leverage technology to extend the capabilities of the care team to augment the clinician/patient relationship, not displace it.” Along those lines Crossover uses an in-house data analytics platform to which Crossover can access a patient’s medical history, recommend evidence based treatments for high risk patients or those with high cost chronic conditions. The Differentiator(s): Crossover employs all of it’s physicians. Physician compensation is composed of salary plus outcome based incentives in order to keep the clinicians’ interests aligned with those of its employer clients. According to CEO Shreeve, employing physicians, creating coordinated care teams and even the physical design of the clinic facilities is part of a top down effort to “have that relationship with the patient” and use it as a competitive differentiator. Shreeve added that each patient care team can manage a “maximum of 10,000 patient lives to maintain a consistent quality of care”. Unlike many other models, Crossover also gets paid by employers on a subscription basis per employee per month (PMPM) or on a per population basis which improves employee access, the depth of the relationship with care teams, removes the transactional nature of the visit and helps lower costs. As noted by CEO Shreeve, “you can’t control costs unless you control healthcare delivery”. The Big Picture: Despite the tremendous increase in the use of telehealth during COVID the quality, convenience and level of customer service surrounding the transaction did not noticeably change. However, providers like Crossover which focus on creating and maintaining a relationship with the patient, where the patient is at the center of the relationship have the potential to improve the level of customer engagement and satisfaction with care and by doing so improve outcomes and lower costs. For far too long, healthcare has lagged behind most other consumer facing industries in the quality and convenience of its relationship with consumers, often making the location of care or the clinician the focus of attention at the center as opposed to the patient. Moreover, by failing to create this relationship physicians have likely failed to leverage their talents to the fullest. For example, according to the Accenture Digital Health Consumer Survey 2020, when asked “which of the following would motivate you to take a more active role in managing your health”, more respondents answered “a trusted healthcare professional who works closely with me to manage my wellness” (55%). In addition, as empowered by more convenient and more accurate technology consumers are increasingly taking charge of their own care. As such they are more willing to share their health data and embrace virtual tools to help them accomplish their goals. For example, According to the 2019 Global Health Care Consumer Survey, almost 60% of respondents are willing to share health data with their doctor to help provide better care, while 44% of respondents would be willing to use an at home test to identify a health risk and 47% of respondents would be willing to use an app to track changes in their vital signs. All of these imply that provider organization and individual clinicians are increasingly going to have more personalized and more strategic relationships with patients through vendors such as Crossover who can build relationships and leverage technology to improve care. The Brainchild of an ER Doctor, Crossover Health Focuses on Data and Preventative Care; Digital-Backed Care Provider Crossover Health Hauls in $168M Series D

Our Take: According to the article, “America’s Health Literacy: Why We Need Accessible Health Information”, only 12% of adult Americans demonstrate limited (proficient) health literacy. This impacts overall health outcomes and healthcare expenditures due to a fragmented education system in the US where health education is not standardized. The cycle of poor health literacy contributes to the prevalence of preventable diseases. Integrating Community Health Workers (CHW) into the healthcare system will reduce the burden placed on strained resources and overworked clinicians. It will also help improve health outcomes when used for addressing chronic health conditions (chronic conditions are usually preventable). Key Takeaways: Community Health Workers will: Cost-effectively address the need for healthcare professionals Implement preventative care more closely, reducing the burden on healthcare services Efficiently improve health outcomes, especially for chronic conditions Close gaps between doctors and patient, acting as a mediator Explain medical shorthand to patients while supporting them with potential social services Improve health literacy in a sustainable manner The Problem: Social determinants of health allude to which populations often face extraneous barriers when accessing healthcare. We often overlook the barriers to receiving and complying with treatment plans even when, finally, inside the hospital room. It often starts with the rigid communication between healthcare providers and patients who often do not correctly understand the medical jargon given the poor health literacy in America. In addition to the poor health literacy noted above, in many communities, the formal medical community itself is not the primary means by which healthcare information is dispersed and providers may not be those most trusted to deliver that information. Moreover, even in communities where health literacy may be strong, they may not have good access to services or supports based on their geographic location. The Backdrop CHW’s are defined by the American Public Health Association as frontline public health workers who are trusted members of a community and who have an unusually close understanding of the community served. This relationship allows CHWs to serve as a liaison with the community to facilitate access to services and improve the quality and cultural competence of service delivery. A community health worker also builds individual and community capacity by increasing health knowledge and self-sufficiency through a range of activities such as outreach, community education, informal counseling, social support, and advocacy. CHWs also function as cultural translators. For example, if English is not the patient’s first language or if Western medicine is not commonly practiced in their culture; patients are less likely to comply with or adhere to their treatment plans. Language is an extension of a culture where the semantics of certain words are accessible to in-group native speakers and where the meanings of certain words get lost in translation. In situations like this, CHWs can step in and improve communication. As patients often interpret symptoms and share information according to how they understand the question and their health, doctors may not end up with an accurate picture or truthful assessment of a patient’s health. As a result, there is a need for certain interventions and clarifications to bridge this gap. In addition, at times, healthcare professionals may not have the skills, personality, or luxury of time when presenting highly complex information to demonstrate cultural competence as their focus is the medical problem itself. No matter what the cause, as demonstrated during the Coronavirus pandemic, health inequities exist across demographics and geographic populations. Moreover, telehealth and digital tools allow providers to leverage services like these. For example, telehealth comes with supportive data infrastructure and can help make access easier for the rural population. The data infrastructure, often in the form of digital health tracking devices or applications supported by smartphones can now be leveraged to tackle poor health outcomes on a larger scale. More importantly, these tools can be programmed to give us sustainable positive health outcomes. (Example: Ginger, telemental health) Implications: CHWs will help make healthcare more accessible for consumers while promoting health literacy and fostering trust in the healthcare system. Medical mistrust is a cultural phenomenon that is shared within groups. As consumers of healthcare services, patients are often at the risk of mistreatment, mismanagement, or a simple lack of understanding in terms of clinical care and disease prevention. This can result in underutilization or poor application of healthcare services. Add in the historical implications of hospital malpractices and lack of general equity and the medical mistrust is likely to follow amongst consumers. Small interventions like these can ultimately improve health literacy and have big impacts. For example, the Mississippi Delta Center implemented CHWs in a program aimed at helping treat heart disease in 18 BIPOC neighborhoods. Studies of the program reported that patients with hypertension who were enrolled in this program reported a decrease in both systolic and diastolic blood pressure as well as an improvement in cholesterol levels. The studies also found a median change in health care costs, post CHW intervention of $82 per person/per year (with the range being -$415 to $14). In addition, health education and health literacy must be comprehensive because health is a multidimensional subject where all aspects of health are interconnected. The lack of health literacy and self-efficacy across populations is one of the main drivers behind America’s high mortality rates, low life expectancy, and the highest rates of preventable deaths. Ultimately, persistence and effective health interventions will lead to less adverse health outcomes. Related Reading: America’s Health Literacy: Why We Need Accessible Health Information Integrating Community Health Workers on Clinical Care Teams and in the Community Exploring Four Barriers Experienced by African Americans in Healthcare: Perceived Discrimination, Medical Mistrust, Race Discordance, and Poor Communication Health Disparities: A Barrier to High-Quality Care

Event: Canvas Medical, a San Francisco-based AI-powered electronic medical records startup, recently raised $17M in Series A funding. The round was co-led by Inspired Capital and IA Ventures with additional participation from existing investor Upfront Ventures. The company plans to use the funds to build new partnerships with insurers, to grow its business among virtual first clinics and, to meet regulatory goals to allow it to receive federal incentive payments. Description: Canvas is an EMR startup targeting small to mid-size PCPs ranging from sole practitioners to practices with up to 50 clinicians. According to the company, they offer a fully integrated platform that can run all of the administrative tasks of physician practices as well as reduce the amount of time doctors spend entering patient data, diagnoses, and tests into EMRs. For example, according to the San Francisco Business Journal, Canvas has eliminated the need for doctors to click through multiple menus when entering data. Instead, Canvas’ machine learning and statistical modeling software organizes and classifies the information in real-time so that all clinicians need to do is type the information onto a blank page. This allows clinicians to focus on the work of caring for patients and less on entering data into an EMR which has shown to be a major drain on physician productivity and contributor to physician burnout (please see “U.S. Clinicians Spend 50% More Time in EHR than those in other Countries” in the 12/22/20 edition of the HSB blog, link here). According to Canvas Medical CEO Andrew Hines, their product can make doctors 30% more productive in the first month of use and help reduce the amount of time spent on charting by 1-2 hours per day (clinicians typically spend 2 hours in the EMR for each hour of direct patient-facing time according to a study in the Annals of Internal Medicine, ). In addition to time and cost savings, the Canvas Medical EMR is designed to better align practices with value-based care models, where payments are tied to outcomes instead of volume. This allows practices to better track and attribute outcomes to the measurements required by insurers under these contracts. Implication: While the move over the last several years to greater use of EMRs had helped providers and payers collect and generally exchange larger volumes of data, it has come at the cost of a dramatic increase in demands on clinicians. As noted, the average physician now spends over two hours in an EMR for each hour of patient care and an additional 1-2 hours of so-called “pajama time” entering records after hours to catch up on record keeping. Solutions like Canvas Medical’s can not only help reduce stress on overworked physicians but also improve coding and the quality of patient care. In addition, given their solution was designed and built to capture and supply both providers and payers with the data needed to measure and attribute care under value-based models, they will facilitate the movement of more physicians to risk-sharing models. Moreover, by eliminating the need for physicians to click through multiple screens to find the appropriate field to input data, less data is likely to end up in unstructured free text fields reducing miscategorization or missing data which should improve the data integrity and data completeness of clinical files. Medical Records Startup Raises $17M to Grow Partnerships with Insurers and Double Workforce & EHR Startup Canvas Medical Raises $17M and Partners with Insurance Heavyweight Anthem

Event: The introduction of augmented reality (AR) and virtual reality (VR) into healthcare has tremendous potential to improve access, lower costs, and give patients a better understanding of their health. Over time it should help to improve overall long-term health outcomes. Previously, AR, VR, and spatial computing have been used in healthcare on a limited basis, but the broad rollout of 5G communications bandwidth and technologies will allow providers to integrate these technologies more broadly into the delivery network. As the pandemic continues, many providers are looking to virtual and augmented reality tools to enhance/expand the scope of procedures offered, facilitate medical training for difficult procedures, build better connections with patients both on and off-site, and support more personalized care. This is especially true in scenarios where the geographical distance or lack of specialized clinicians may limit available services. The inclusion of these technologies can introduce a different perspective of healthcare that will benefit the populations for generations to come. Description: Augmented reality (AR) is a technology that combines real-world and virtual elements. The implementation of this tool in a healthcare setting is useful when trying to get patients to become more engaged with prototypes and for helping them understand a key component to their care. Virtual reality (VR) is a computer-generated simulation where people can interact within an artificial three-dimensional environment using electronic devices. It stimulates vision and hearing, causing the user to feel like they are actually sensing and feeling the simulated reality firsthand. This includes the use of a specialized headset with a built-in screen as well as gloves fitted with sensors. Although both use the same types of technology to create an enhanced experience, AR is more accessible through mobile devices, laptops, smartphones, and tablet computing devices and VR is usually delivered through a head-mounted or handheld controller. During COVID-19, many countries faced challenges due to a shortage of doctors, excessive workload, and less access to in-person doctor’s visits. Although other telemedicine options were given, the use of AR significantly improved patient’s experience. According to a study entitled “Combating COVID-19—How Can AR Telemedicine Help Doctors More Effectively Implement Clinical Work” AR telemedicine could be put on smartphones and tablets that were easy to navigate for consultations, instructions, and demonstrations from their providers, and for self-monitoring purposes as well. For example, the shortage of primary care physicians during this era has resulted in many newer physicians with little respiratory care experience coming into practice. Using AR video fusion and labeling function, respiratory experts were able to conduct real-time remote guidance and training in respiratory medicine. This is especially important in rural areas, where physician shortages, accessibility, and travel costs have always been barriers to care, particularly for the disadvantaged and those in underserved areas. In addition, through AR/VR technology, experts were able to conduct remote ultrasound guidance, emergency remote rescue, remote surgical guidance, as well as guide clinicians remotely in many other procedures. They were also able to blend computer-generated images and data from MRI and CT scans with real world views to allow doctors to visualize the patient’s bones, muscles, and internal organs without having to perform surgery. The images and findings could then be shared with other healthcare professionals to be further analyzed, decreasing the likelihood of misdiagnosis. According to an article from the Borgen Project, “5 Technologies Improving Healthcare in Rural Areas”. Purdue University created an AR technology that allowed more experienced medical professionals to assist inexperienced doctors and surgeons with fewer tools and materials yet complete certain procedures, ultimately maximizing the patient’s outcome. Additionally, the introduction of 5G, the fifth generation of cellular wireless data has helped to further enhance healthcare professional’s ability to deliver innovative, less invasive procedures. According to an article from Health Europa,”Why 5G Enabled Healthcare Is Important for Patients and Spatial Computing”, this technology offers better connectivity and broadband speeds that are required for streaming during remote surgical procedures. With the broader development of the technology, AR/VR development is also getting easier and cheaper as 5G is now becoming more accessible on cellular devices, enabling faster downloads and streaming on devices that many people already own or can more easily afford. Moreover, more powerful and affordable headsets are increasingly coming onto the market empowering more widespread consumer access and use, particularly in healthcare applications. Implications: The introduction of AR and VR into healthcare settings has significantly impacted health disparities and access to health issues as it gives alternative options for patients to access resources they need using this technology. With the shift to greater use of telehealth, as well as improvements in technology and communications there’s been an increase in more affordable equipment for patients as well as healthcare providers. While there was improved access to telemedicine visits and increased insurance coverage during COVID due to a relaxation of regulations and waivers, it will be incumbent on healthcare organizations and regulators to find a way to adopt the use of these technologies as a standard of care. Incorporating AR and VR technologies into certain visits and treatment will ensure a better patient experience and optimal outcomes. Moreover, these technologies facilitate improvements in training, guidance, and collaboration among physicians, especially those in rural areas with fewer resources, allowing providers to better assess ailments, perform difficult surgeries, and disintegrate existing barriers to care amongst vulnerable populations. As AR and VR continue to become more broadly used and accepted in healthcare they can continue to make care more efficient, increase access, improve patient outcomes and solidity provider/patient relationships. Combating COVID-19—How Can AR Telemedicine Help Doctors More Effectively Implement Clinical Work; 5 Technologies Improving Healthcare in Rural Areas; Why 5G Enabled Healthcare is Important for Patients and Spatial Computing Dr. Google Actually Improves Diagnostic Accuracy Event: A recent article in MobiHealthNews discussed a new study published in JAMA, which examined the association between an internet search for health information (often referred to as checking with Dr. Google) by nonphysicians and improved accuracy in diagnosis and triage. The study concluded that an association exists and online investigations for self-diagnosis lead to slightly more accurate diagnoses. Description: This study comprised survey results of 5,000 adults asked to assess validated case vignettes of common illnesses like viral infections to severe conditions like heart attacks. Participants spent an average of 12 minutes researching the symptoms before concluding their diagnosis. They were asked to relay their diagnosis, triage, and anxiety regarding one of these cases before searching the internet for health information. The study found that 49.8% of participants correctly guessed the health condition being described prior to the internet search, and that result improved to 54% following the search. Improvements in diagnostic accuracy occurred across all forms of triage categories provided: emergent (3.1%), same day (3.5%), same week (6.4%), and self-care (3.7%). Finding useful information was difficult for participants, but they said the most helpful online resources were search engines (48.2%) and health specialty sites (42,9%). Researchers explained that performing an internet search was associated with an improved diagnosis. Implications: Checking symptoms online is common among adults even though most patients are generally advised not to self-diagnose themselves. This is generally because clinicians fear that self-diagnosis using the internet can lead to inaccurate diagnosis, incorrect treatment, or increased anxiety about the seriousness of the illness. Between 2012 and 2013, 72% of people used the internet to look up health information, and 35% were classified as “online diagnosers.” Websites such as WebMD have taken steps to make their symptom-checkers more accurate, and there are numerous other apps on the market that can help people diagnose and triage symptoms. These sources provide a convenient way to pinpoint what condition a person’s symptoms may indicate. A 2018 review of direct-to-consumer self-diagnostic apps found that apps vary widely in functionality, accuracy, safety, effectiveness. While the generally accepted advice has been to instruct patients not to diagnose themselves the results of this study may indicate that a better approach may be to help guide patients to improve their diagnosis. This would include assisting them in what questions to ask, simple signs that may help them distinguish the severity of conditions, and when self-diagnosis may simply be impossible given the range of symptoms. Internet Searching Found to Improve Layperson Diagnostic Accuracy Population Health Platform, IBH To Acquire Digital Mental Health Company, Uprise Event: A recent article in MobiHealthNews reported that IBH, a tech-enabled population health platform, recently completed its acquisition of digital mental health company Uprise. The acquisition will give IBH access to the Uprise platform which provides self-guided mental health tools delivered via self-guided modules, live coaching, and in-person therapy. The acquisition will also allow the two companies to merge large data sets, which can be used to gain insights into members' needs. Description: Both companies, IBH and Uprise, work in the employer health space and focus on behavioral health. According to the press release, IBH, “offers digitally-enabled employee assistance programs bolstered with personalized coaching, chronic condition management, managed behavioral health, data analytics, and opioid assessment and treatment solutions.” IBH focuses on behavioral health, substance abuse monitoring, maternity management, and both population and occupational health. Uprise’s platform also allows employees to complete a well-being checklist and those who are “designated at risk get a call within 24 hours of their assessment and are then triaged to appropriate services.” The company offers telehealth services as part of its employee assistance and managed behavioral health programs. Implications: Behavioral health issues are common in the U.S., and employers focus on employee mental health has become a significant objective of employers around the world. IBH's acquisition of Uprise should help them gain scale in the Employee Assistance Program (EAP) space and leverage the advantages of larger data sets to population health in the field of behavioral health. This is especially important during COVID as, according to the CDC, 11.2% of adults report feeling worried, anxious, or nervous, while another 4.7% report regularly feeling depressed. In addition, the American Psychiatric Association reported that depression is the leading cause of disability worldwide and costs the U.S. economy roughly $210 billion a year due to absenteeism, reduced productivity, and medical costs. Many digital health companies like IBH and Uprise have begun focusing on the employer mental health space. Other companies like Modern Health, a mental health and wellness platform, have also been looking to grow with Modern Health recently raising $74 million in February and Unmind in the U.K securing $10 million in funding for its workplace mental health platform in February of 2020. Population Health Company IBH Snaps up Mental Health Focused Uprise Surgical Specialty Pre-Op and Post-Op Telehealth Visits Slow After June 2020 Event: Healthcare IT News reported on a study conducted by JAMA on the use of telehealth by surgical specialties during the COVID pandemic. The Michigan-based surgical specialties found 58.8% of the 4,405 active surgeons used telehealth during the peak of the pandemic. The conversion rates- defined as the rate of weekly new patient telehealth visits divided by the mean weekly number of total new patient visits in 2019 showed 109,610 surgical new outpatient visits from March through September 2020. Of those, 6.1% (6,634) were telehealth visits compared with 8 telehealth visits (<0.1%) during the same time in 2019 Description: The field of surgery readily adopted telehealth during the pandemic and was a major modality of health care delivery. Prior to the pandemic, the Surgical field was using telehealth for the preoperative and postoperative follow-up visits though the numbers were significantly less. Among surgery, the highest utilization of telehealth was seen among neurosurgery and urology and the lowest was seen in the orthopedics and ear, nose, and throat (ENT) departments. In addition, the Kane and Gillis cross-sectional study also reported that surgical specialties’ use of telehealth was 11.4%, the lowest among service lines. For example, telehealth utilization ranged from 12.7% in primary care to 39.5% in radiology. Surgical telehealth adoption prior to the pandemic was difficult to adopt which resulted in a decline in the surgery telehealth services when in-person clinics started to reopen. This was due to patient reservations who had initially postponed appointments as they preferred in-person visits as well as hesitancy among surgeons. With the policy-level barriers, surgeons found it concerning investing time and resources to update clinical workflows to learn new patient engagement through telehealth which they perceived would likely be an added burden. In addition, there were also patient barriers that prevented the use of telehealth which included: lack of private space, poor connectivity, no device on which to contact clinicians, and digital literacy. Implications: During the pandemic, telehealth was one of the best modalities to reach patients given the lack of in-person visits and the need to protect patients from exposure to COVID infection. Nevertheless, the adoption of telehealth by surgical specialties remained particularly difficult when compared with other specialties. Not only were there reservations from patients, but there were also reservations from clinicians. For physicians, the main concern was about the inability to perform physical examinations properly or not being trained on proper methods to conduct physical examinations via this platform. As physical examinations are used to diagnose and determine treatment plans, enrolling surgeons in training initiatives on how to properly engage and evaluate patients via telehealth platforms would encourage both surgeons and patients to utilize this platform. In addition, adding training via residency and fellowship curriculums would also boost the use of telehealth in specialties that are still hesitant to use this platform. In addition, clinicians should also be mindful of technological barriers to access such as availability of technology and broadband communication services which may prevent patients from utilizing telehealth. Bearing these in mind, these factors should be discussed and addressed by patients and clinicians, for the broadest group of those seeking care to realize the benefits of telehealth. Telehealth for Surgical Specialties Saw a Slow Decline After June 2020