Search

Our Take: Increased adoption of telehealth will improve patient satisfaction and outcomes. Telehealth has become a core part of the healthcare system in the U.S. following a dramatic increase in use during the pandemic. Providers and payers have implemented new platforms into their care delivery systems to more directly cater to patients’ needs. The combination of a number of these tools all of which encourage flexibility and patient engagement, including 1) Home-based diagnostic tools, 2) Digital self-service tools, and 3) Wearable healthcare devices leading to better health outcomes, reductions in no-show rates, and improved patient satisfaction. While the pandemic may have been the catalyst, the trend towards incorporating telehealth into care delivery plans will continue forcing providers to work towards better delivery of services through a digital medium to create a more user-friendly and customer satisfying experience. Description: As a result of the pandemic, digital health has proven to be a convenient means to receive proper care in a timely manner. Prior to the pandemic, only a small minority of patients routinely utilized digital health tools to track their health conditions or visit doctors. While the adoption of digital health was slowly advancing and was recognized as having great potential for the delivery of care, it hadn’t caught up to speed. COVID fast-tracked the whole dimension in the use of technology in healthcare. Consequently, more than ever with the incorporation of digital tools and patient/provider acceptance, technology has become a crucial part of the healthcare delivery system. Along with increasing use and increased choice in offerings has come improved patient satisfaction. For example, according to the J.D. Power 2020 U.S. Telehealth Satisfaction Study, overall patient satisfaction score across all telehealth providers came in at 860 on a 1000-point scale. This was the highest patient satisfaction score for a healthcare service study ever done. According to Symphony Performance Health Analytics (SPH), 70% of patients preferred virtual visits over in-person visits to save time. Similarly, according to a study entitled “Reduced No-Show Rates and Sustained Patient Satisfaction of Telehealth During the COVID-19 Pandemic”, the convenience of telehealth services reduced caregiver burden for a certain patient demographic and saved travel time and cost as well. They reported, “telehealth is not only advantageous for patient satisfaction but also for increasing the efficiency of healthcare resources by significantly reducing patient no-show rates.” The study demonstrated a 7.5% no-show rate for telehealth visits as compared to the in-person no-show rate of 29.8%. The Cleveland Clinic is also conducting a study to compare no-shows among in-person visits and virtual visit appointments. While the study is ongoing, based on Cleveland Clinic’s historical experience, the hypothesis estimated a 76% in-person no-show rate and 51% for virtual visits. The assumption is that no-shows are due to poor engagement, inconvenience, and difficulty of getting to appointments. Health systems and clinician practices consistently report lower no-show rates with telehealth, especially in behavioral care where telehealth removes the stigma of visiting a behavioral clinic. For example, the baseline no-show rate for psychiatry services is between 19 and 22 percent of appointments – while MDLive reports no-show rates of only 4.4-7.26 percent for its behavioral health telehealth visits. Implications: Telehealth uses technology to provide convenient, high-quality care and patient access, which ultimately leads to improved patient satisfaction and outcomes. As many of the healthcare systems rolled out broader telehealth services they acknowledged their patients easily adopted telehealth as they didn’t have to deal with transportation issues, take time off work or find childcare in order to make it to their appointments. While this required additional investment in technology and services to cater to patients’ needs, it also led to a decrease in no-show rates, long a challenge for the industry. Nevertheless, while improvements have been made, patients also reported varying degrees of satisfaction with their healthcare payers, many of which provided telehealth services through their health plan benefits. For example, Cigna was the top-ranked payer-provided telehealth service, receiving a patient satisfaction score of 874, with the Kaiser Foundation Health Plan getting a score of 867, ranking second, while UnitedHealthcare ranked third, with a score of 865 out of 1,000. However, though telehealth convenience has been acknowledged there are barriers that need to be addressed. There are still limited services, technology requirements are confusing as some patients are not as technologically-savvy, and issues remain with broadband availability. Enhancement and expansion of telehealth will further improve health outcomes as well as satisfaction but that will depend on policymakers, governments, and perhaps public-private partnerships to make broadband access more equitable and available. In-person care has been leading to an increasing number of missed appointments which ultimately decrease care plan compliance and lead to more expensive care needs. However, telehealth has shown offsetting effects on no-show rates along with better care plan adherence which has contributed to downstream cost savings likely mitigating some of the incremental costs. In addition, digital tools such as telehealth, remote patient monitoring, and virtual care could likely aid in reducing costs for patients requiring costly long-term chronic care, which can be done in the comfort of the home, For example, in diabetes care management, routine visits can help prevent long-term costly effects, yet patients often end up missing their monthly/3monthly check-ups due to inconvenience- this ultimately hampers their health leading to a rise in the cost of care and additional potential complications.. As policymakers evaluate the proper guidelines for telehealth, and with oversight bodies such as MedPAC saying they want to take 1-2 years’ time evaluating telehealth’s impact on outcomes before changing regulations, it is imperative that indirect costs such as these be considered in the equation. In addition, NCQA also reported the need to consider telehealth’s impact on no-show rates. If we truly want to move to a value-based paradigm, telehealth must not be viewed just as a replacement for episodic in-person visits, a key element in a model of continuous care given its ability to make delivery more convenient and easily accessible with more frequent but shorter encounters. This model provides many more opportunities for early testing, diagnosis and intervention for the health of the patient. Telehealth should further aim to improve the quality of healthcare, with special attention to overcoming existing barriers in access to care, including the burden of time and financial costs that patients and families bear in non-medical costs such as lost work, wages and the need for family caregivers associated with traditional in-person visits. Patient Satisfaction with Telehealth High Following COVID-19; Findings and Recommendations: Telehealth Effect on Total Cost of Care; Reduced No-Show Rates and Sustained Patient Satisfaction of Telehealth During the COVID-19 Pandemic How Can Hospitals Prepare for the Hospital at Home? Event: Healthcare IT News recently interviewed Tom Kiesau, Director and leader at Chartis Group, a healthcare advisory and analytics firm. Kiesau discussed the importance of identifying the right patient populations that stand the most benefit from acute care remote patient monitoring as organizations move toward expanded use of the hospital at home in the near future. The article emphasized that more hospitals and health systems are pushing to expand remote patient monitoring programs – up to and including the provision of acute care at home. Description: The hospital at home is a clear pathway for parity reimbursement during public health emergencies, and it is here to stay. On the contrary, many questions remain as regulations and reimbursement mechanisms are unpredictable as momentum builds behind the concept of hospital at home. Amazon has teamed up with blue-chip health systems such as Ascension and Intermountain for the new Moving Health Home collaborative, whose goal is to "change the way policymakers think about the home as a site of clinical service." The group plans to lobby policymakers to broaden coverage for care services in the home, which include expansion of the Centers for Medicare and Medicaid Services' Hospital Without Walls provisions – advocate for bundled-payment models, home-based care, and more. Based on this goal, Kiesau implied that health systems should be prioritizing their investments in patient-facing tools and technologies, command centers, delivery services, administrative support, IT infrastructure, and more. He also explained that the hospital of the home bears many benefits such as lower costs, reduced readmissions, and may be a better replacement for acute care. Yet, a paradox exists because clinical populations must be identified that are deemed appropriate for remote services. Once this is resolved, thought must be given to what unique tools are needed to service these populations, the financial implications, and economic viability. Understanding the population that one intends to serve involves looking at the data you will target and how the hospital at home would impact them. Many organizations figure that a hospital at home model will provide a better experience with increased positive outcomes and reduced readmission rates. The interview also addressed considerations that should be given if unforeseen problems occur, such as unreliable internet connection or how someone would get into a patient's home if there is a medical emergency. Implications: According to the study, Telehealth: A Technology-Based Weapon in the War Against the Coronavirus (2020), researchers predicted that the pandemic would continue to reshape care delivery and provide major opportunities for virtual care. Researchers were right because the COVID pandemic prompted an enormous uptick in virtual care use from patients and providers. Telehealth, remote patient monitoring, digital therapeutics, provider home visits, and shareable medical records have "shown that care in the home can be at least equivalent to, if not better than the care offered in facilities." The “hospital at home” will provide flexibility to patients and providers alike by offering remote support through a digital infrastructure that will take the place of major health institutions. As discussed in the interview, the hospital at home will lead to better patient experiences and clinical outcomes by providing convenient and cost-effective access to patients seeking care. The CMS estimates that home health care in Medicare will save at least $378 million a year in just the nine states that are part of the Home Health Value-Based Purchasing. Additionally, research shows that home-based care is likely to reduce hospital readmissions by about 25% within 30 days of discharge. This new transformation of healthcare at home makes it possible for clinicians to observe, report, and analyze patients' acute or chronic conditions, no matter their location and in real-time. How Health Systems Should be Preparing Now for the Future of Hospital at Home & Health Systems, Care Delivery Groups, Amazon Launch Hospital-At-Home Initiative Leveraging Real-World Data in Cross-Sector Partnerships Event: A recent article in MobiHealthNews highlighted presentations from the HIMSS’ Accelerate Health event. During the event, Christopher Boone, VP and Global Head of Health Economics and Research Outcomes of Abbvie shared his game plan for how stakeholders can use big data. According to Boone, big data can be used to further the quality, safety, and effectiveness of drug therapies in a post-pandemic environment. He suggested leveraging as many lessons as possible from his pandemic experience to institutionalize them in the health system. Description: During the event, Boone explained that big data can be used to reimagine clinical discovery, clinical development, and commercialize drug therapies. Using real-world data gathered outside of the clinical trial setting and used across the life cycle of drug development must be expanded in order to achieve this. This kind of data will be used to determine the feasibility of clinical trials, recruit participants, inform regulatory safety decisions, lead commercialization and customer support programs. It is essential to have this data to understand the benefits and risks of all drug therapies and think about what precision health looks like from a cross-sector partnership perspective. Boone added three strategic steps that can be taken to achieve quality, safety, and effectiveness of therapies include: 1) Establish a shared vision and agenda for clinical practice and development focused on the issues of all communities, specially those facing health disparities; 2) Develop a joint plan of action that addresses systemic racism, inequalities, social determinants and diversity; and, 3) Invest in foundational data analytic capabilities such as curation, tagging, linking and searching to allow for public health surveillance. Implications: As the world begins to move towards the end of the pandemic, stakeholders are strategizing on how to use the lessons learned and apply them to a post-pandemic environment. As noted in the article, it is essential to understand the needs of individuals based on trust and transparency. In addition, siloed sectors of the industry need to form new models of collaboration. New cross-sector relationships among pharmaceutical companies and provider organizations will provide many opportunities for both sides and patients. As part of the transition to value-based care, pharmaceutical companies can demonstrate their therapies' effectiveness while giving providers the benefit of optimizing treatment for better outcomes and allowing them to achieve their value-based goals. The three strategies outlined above will facilitate faster, better, and cheaper clinical discovery and development efforts of drug therapies. These strategies suggest how partnerships can continue to be created and sustained, overcome hurdles, and build trust between two entities, which is key to success. Leveraging Real-World Data in Cross-Sector Partnerships is Key to Advancing Clinical Development Drones That Can Make Telehealth House Calls Event: On March 19th, mHealthIntelligence reported that researchers at the University of Cincinnati are creating a drone with the ability to make telehealth house calls. With the emergence of the COVID pandemic causing the increased need for telehealth care delivery, the creation of this tool is vital to improve patient’s accessibility to healthcare resources and to ensure that those with life threatening or chronic illnesses are still receiving care while still social distancing and avoiding potential exposure to the Coronavirus. Description: The drone has several features and capabilities that will greatly aid users with telehealth needs. According to the article, it includes an audio-visual telemedicine platform along with a waterproof compartment for carrying medical supplies and sample tests. With its small design, it can effectively maneuver into and around a patient’s home to bring patients their essentials. Researchers are also not limiting the drone’s capabilities to inside homes and medical facilities but are also exploring its ability to deliver medications, supplies, and labs to the country’s most secluded regions. This will enable clinicians to conduct many different functions including chronic disease management, post-operative care monitoring, health coaching, and consultations. Additionally, the drone may have applications where living conditions need to be assessed and even deliver interventions in special cases when a patient may be unable to contact anyone. This is pivotal in the case of the elderly or disabled patients, who live alone, especially during the pandemic. Implications: While the drone is still exploratory, adoption of it and other devices like it can help fill a void for patients with a lack of access to healthcare resources. For example, such devices could be used in rural areas to provide services to those who routinely cannot access care due to limited access in transportation. Devices like the drone are very timely in that many people continue to test positive for COVID and still need medications and everyday resources while remaining in quarantine. This is especially true in rural areas, where people already face issues of limited access to physicians and healthcare facilities, grocery stores, and other essentials. This drone could easily be coupled with telehealth systems, to help fight health inequality and help reduce other negative factors associated with the social determinants of health. Researchers Work on a Drone That Can Make Telehealth House Calls UnitedHealthcare Launches Virtual Hearing Aid Program Event: On March 18th, UnitedHealthcare unveiled a new virtual care option called Right2You. The program expands access to custom-programmed hearing aids that will potentially reduce the need for in person appointments for fittings or adjustments. The introduction of this product will provide greater convenience and affordability for eligible hearing impaired UnitedHealthcare members, addressing any disparities patients may face with traditional models which typically require an in-person visit to an audiologists office. Description: The introduction of the Right2You hearing device is based on UnitedHealthcare’s already established home delivered hearing healthcare model. The device adds a virtual care component that is designed to reduce the need for in-person appointments for hearing aid adjustments and support. According to the article, eligible patients can take an online hearing test to determine what their current hearing status is and if the tests indicated potential hearing loss, the patient could obtain the results of the audiogram from an in-person appointment with an UnitedHealthcare Hearing audiologist or another credentialed hearing healthcare provider. Custom-programmed hearing aids are then shipped directly to the person’s home. According to UnitedHealthcare, the program allows further customization remotely with a smartphone or tablet paired to the hearing aids instead of through an in-person appointment. They can then have the custom hearing aids sent to their homes. For those who don’t wish to take advantage of the online model, the program also allows the option for patients to see an audiologist from United’s large network or credentialed audiologist and hearing professionals. Implications: As a result of the pandemic, hearing aid sales have declined significantly as patients who are at risk seek to avoid exposure to COVID. This is a major issue since there are more than 48 million Americans with hearing loss and a number of viable solutions exist to improve the quality of their lives. This virtual care option removes the barriers to care that have developed because of the pandemic, enabling people to conveniently receive treatment while minimizing exposure to COVID through this virtual platform. Hearing significantly impacts overall well-being, therefore, improving the cost and access to hearing health treatment and hearing aids will help to improve overall health outcomes. UnitedHealthcare Hearing Launches Virtual Option to Help Plan Participants Remotely Access Hearing Health Care and Treatment & UnitedHealthcare Launches Virtual Hearing Care Program

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

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?

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: 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: As one of the steps towards improving coverage and access to health care coverage in the United States, Medicaid should shift to an auto-enrollment mechanism, whereby beneficiaries are automatically-enrolled in coverage by some sort of mechanism (separately determined), without requiring them to actively seek out coverage or submit an initial application. Medicaid, is designed to cover people near or below the Federal Poverty Level (FPL), but unlike Medicare, its federal counterpart for those over 65 or with a disability, Medicaid and the Children's Health Insurance Program (CHIP) do not have any auto-enrollment mechanism in place. As a result, low income individuals, many of whom live in underresourced areas and lack transportation, must currently take affirmative action to seek out and sign up for their government-funded health insurance benefit. Intended or not, this effectively leaves millions of eligible Americans without healthcare coverage leading to a debate as to whether costs and quality would be improved if they were automatically enrolled in the system. Description: The current U.S health insurance system is dominated by employer sponsored coverage (ESI) which covers approximately 155M employees and their beneficiaries. Many others get access through the health insurance marketplaces set up under the Affordable Care Act (ACA) and may or may not receive subsidies to help them pay for premiums under the ACA as a function of income. Medicare currently covers nearly all citizens and permanent residents over age 65 or with a disability automatically. This is also true of the CHIP which covers children whose parents or guardians have income too high to qualify for Medicaid but low enough that affording insurance for an entire family is difficult. This patchwork system still leaves a large portion of the population lacking access to health insurance coverage through these means, but generally eligible for Medicaid. Medicaid is a state-run but majority federally-funded program with the federal government setting baseline benefit and eligibility standards but different states have different eligibility and coverage thresholds. However, as noted above, while many may be eligible for coverage they still must enroll to receive benefits, which leaves many uninsured. According to Kaiser Family Foundation, 27% or 8.8 million of the 32.3 million total non-elderly uninsured in the US were eligible for Medicaid or CHIP in 2016. While the age composition of this eligible unenrolled group varied by state, Kaiser found that 18% were adults eligible for Medicaid and 10% were children eligible for CHIP. Moreover, another study found that if those who were eligible had been enrolled by a parent or guardian, the number of uninsured children in the US would have been cut from 3.7 million to 1.6 million. We believe auto-enrollment would help solve the problem of many being eligible for Medicaid but not enrolling, and there is evidence it works. By way of illustration, studies indicate that auto-enrollment is helpful in retaining beneficiaries who may have let their coverage lapse. For example, a September 2019 article in the Journal of the American Medical Association (JAMA) found that people who had insurance from the ACA marketplaces that allowed for automatic re-enrollment were 30% more likely to retain coverage the following year than people whose offerings did not include auto re-enrollment. JAMA found while there were several factors that lead to people not re-enrolling in a plan, they included reasons other than a lack of knowledge or willingness to re-enroll. Auto-enrollment is not without its issues for the states, which would face their own set of challenges to implement it. A report from the Brookings Institute found four policy problems for auto-enrollment in health insurance, two of which would pertain to exactly this issue with Medicaid; obtaining eligibility information and managing false positives and false negatives. These eligibility and verification issues both hinge on the availability of comprehensive and quality data. While Medicaid must already obtain eligibility information, this process expands in both scope and difficulty when states are required to find every person who qualifies and enrol them. By contrast, managing false positives is already something done as part of the Medicaid program’s current operations given that they have to deal with fraud cases, however, managing false negatives would be a new task. In determining what method to connect auto-enrollment to a number of solutions have been proposed including enrollment at tax filing (many who qualify for Medicaid are working poor), when people file for unemployment insurance and even when renewing drivers licenses. While none of these methods are perfect, increasing access to coverage would help more people get into the system, improve the quality of their care and ensure that they are receiving care at the right sight of care. Implications: Closing the gap for insurance coverage is essential to promoting the health of Americans. The people who are uninsured are often referred to as the “donut hole,” those whose income falls in between eligibility for Medicaid and the amount necessary to afford private insurance. Policies like CHIP and the ACA were designed to meet that need, and the potential for expansion of subsidies under the Biden administration is promising. Yet, if people who are eligible for Medicaid are not enrolled, the donut has a bite taken out of it, and there is more space to fill. According to Kaiser, a majority of eligible unenrolled people are people of color. In non-expansion states, close to a third are Black, and in total nearly a third are Hispanic. The health metrics for these populations are lower across the board than those of White people. The barriers to enrollment are often unique to underserved communities such as an experience with government and healthcare that has been less than forthright. As a result, there is a history of distrust that is not unreasonable. In addition, given the political divisions around immigration, the federal government has enacted and enforced anti-immigration policies that have an impact on healthcare access. For example, according to the Urban Institute these policies have led to 1 in 5 adults in immigrant families with children to be less likely to claim public benefits such as Medicaid in 2019. Interestingly, as a result, while many of the positions opposing immigration are rooted in the financial burden on state and Federal governments, this may lead to even more accessing of care when a condition is acute and often via the most expensive means (typically the ER). Improving coverage via Medicaid has always been a matter of health equity, but auto-enrollment for Medicaid would help improve coverage for a portion of uninsured Americans who are arguably most vulnerable. A Closer Look at the Remaining Uninsured Population Eligible for Medicaid and CHIP; Association Between Having an Automatic Re-enrollment Option and Re-enrollment in Health Insurance Marketplaces; Three Ways to Make Health Insurance Auto-Enrollment Work NQF Reassess Telehealth Parity and Health Outcomes Event: On March 8th, mHealthIntelligence reported the National Quality Forum (NQF), a not for profit, nonpartisan membership-based organization working to catalyze improvements in healthcare, is planning to update their 2017 framework for measuring the success of telehealth. NQF is going to review it’s 2017 guidance and examine where improvements need to be implemented. In partnering with the Centers for Medicare and Medicaid Services, the organization hopes to improve telehealth platforms to achieve better health outcomes. The organizations are looking to improve health system readiness, especially in areas severely impacted by the COVID pandemic. Description: The NQF is a membership-based organization that brings together diverse organizations such as patients, caregivers, hospitals, healthcare systems, clinicians, insurers and employers. It is made up of over 400 organizations and institutions across the healthcare sector that learn, influence, connect, and become informed on healthcare issues. In partnership with the Centers for Medicare and Medicaid Services, the organization plans to measure how connected health tools and platforms have impacted clinical outcomes, access to care, patient engagement, and the cost of care. According to the article, telehealth resources were scarce and only existed in large health systems in urban areas, disregarding the need for these resources in rural areas that lack access to healthcare due to distance, cost, and lack of physicians. The new studies conducted can help to examine if rural healthcare delivery has been affected by telehealth, particularly looking at usage during COVID. As noted by Sheri Winsper, SVP of Quality Measurement for NQF “telehealth existed in pockets, primarily in large health systems in urban areas. When COVID hit, however, everyone sought to push as much care as possible from in-person to virtual channels, in essence pushing the telehealth development curve ahead by 10 years.” As a result, Winsper added, “the NQF’s mission now is to take the data gathered by the surge in telehealth use and figure out whether it’s solving barriers to care or improving outcomes.” The organizations stress the need to update these measures, especially during a period where all different populations are heavily relying on these platforms to maintain their health and have direct access to healthcare providers at an affordable cost. Implications: With the continued surge of the COVID pandemic, patients continue to rely on telehealth platforms since in some cases, they are still unable to see their physicians unless the situation is critical. It is important to reassess these platforms to ensure that they are meeting the current needs of patients, especially in the case of patients with chronic or life-threatening diseases, where lack of access, or missed follow-up appointments could have been exacerbated due to concern of COVID exposure. Some of the key takeaways NQF can learn from the data include: 1) how telehealth should be compared to in-person care, especially in areas where access to in-person care is limited, 2) how to measure different modalities, should they be measured differently or evaluated against similar standards of care, 3) what information patients should receive when selecting different platforms to access care. This report not only hopes to link the quality of telehealth care with outcomes but also to compare telehealth to in-person care. Clinical evidence of both of these outcomes would be positive to influence post-COVID reimbursement of telehealth which is critical to maintaining usage and expanding into underserved communities. National Quality Forum Looks to Update Telehealth Quality Benchmarks Automated Reminders Help Warren Clinic Reduce Vaccine Waste Event: On March 9th, Healthcare IT News ran an article about the Warren Clinic in Tulsa, Oklahoma which is the hub seeking to provide three million people with the COVID vaccine. Warren is the hub for Tulsa, OK as well as seven surrounding counties. As a result, Warren Clinic's priorities were to develop an effective way to communicate with its patients and at the same time make sure that vaccine doses don’t get wasted, especially given the vaccine's short shelf life. Description: As noted in the article, Warren Clinic is a 450-provider employed medical group that is part of the Saint Francis Health System which would be responsible for distributing the vaccine to 3 million people in Tulsa and the surrounding counties. Given the strong expected demand for the vaccine Warren Clinic wanted to minimize “no-shows'' via automated appointment reminders to ensure none of the vaccine that had been thawed to room temperature would go unused and have to be thrown out. Warren Clinic worked with their long time health IT vendor Relatient which provides their bi-directional appointment-reminder solution that had been seamlessly integrated into their Epic EHR. The Relatient solution helps with direct-to-patient reminders that allows staff to automate text, email, and phone reminders. We spoke with Relatient CEO Michele Perry who added that “you have to engage patients in a way that is going to be super easy...you need a vaccine, here are your options but you still need the basics, how do you get updated medical histories and other information to the doctors.” For example, once Warren Clinic’s patients make an appointment, they receive reminders and their responses, including cancellations, which are then noted in the department appointments report. This way the team can see any new vacancies opened up from appointment cancellations. In addition, as part of Warren Clinic's new Epic EHR build, the first vaccine appointment automatically triggered a second appointment 21 days later at the same time as the first. This strategy was used in an aim for zero waste in vaccine doses as well as minimizing no-shows. Warren Clinic, which had been working with Relatient for five years, had piloted the Relatient automated reminder system earlier at six of its provider locations with the highest no-show rates (unrelated to COVID), and saw an immediate drop in no-shows by 52%. Implications: As noted in the article, among the lessons learned by the Warren Clinic were: 1) patient’s receiving information directly on their phones where the information was easily accessible seemed to contribute directly to the decline in “no-shows”, 2) have vendors who are integrated, such as Relatient and Epic and don’t be afraid to ask them to move fast to help get your strategy in place, and, 3) ensure that when asking vendors for solutions IT integration has already occurred and put until later asking for things that are not integrated, As noted by Collin Henry, Vice President of Operations and Physician Recruitment for Saint Francis Health System, “[have] a myriad of vendors who offer great service, are responsive and act more like partners than vendors. Then leverage those relationships so you can respond quickly and get a plan in place.” Relatient’s Perry added that to achieve this type of partnership with customers from the vendor side “you have to have a healthy balance between anticipating customer needs so you are there for them, and hearing what they say. Customers want to know they have a voice and that they will be heard”. From the Warren Clinic side Henry added that having vendors who “most importantly, ... understand the values and expectations of one's organization – makes the rollout of any new project or technology easier.” As a result, Warren Clinic has been able to use some of the best practices to reduce no-shows including: 1) Setting automated client appointment reminders via multiple mediums (text and email), 2) Allowing patients to confirm via text/email, 3) Automating bi-directional reminders where a patient’s response to the text reminder either confirms their appointment or provides alternative appointment times for them to select, and, 4) Automated patient instructions that include, clinic addresses traffic routes and COVID safety protocols. Warren Clinic Wastes No Vaccine with Help from Automated Reminders How Femtech is Breaking the Taboo Around Women’s Health Event: A recent article in MobiHealthNews reviewed femtech's roles in tackling subjects such as pregnancy, miscarriages, physical shame, menopause, periods, and fertility. Lina Chan, founder, and CEO of women’s fertility platform Parla, noted that these areas have always been understudied because women find it uncomfortable to discuss their health issues. The new femtech movement is working to support these issues and close the health gap to ensure women live happier, healthier, shame-free lives. Description: Women's health care has been shrouded in taboo because women have traditionally been taught from a young age to be ashamed of their bodies. Their health has always been understudied because there have long been various cultural norms that women are always supposed to look pretty, have no flaws, and stay small. Often, women are discouraged from sharing their experiences involving miscarriages and fertility struggles because they are ashamed. However, when women do share these experiences they find out that they aren't the "only ones" who have experienced these situations. As noted in the article, the unnecessary stigma associated with this misguided belief system can lead to isolation and affect a woman's mental wellbeing and physical health. In addition, this can cause women to withdraw from support networks and feel uncomfortable sharing things with providers. According to the article, the only way to end this cycle is to open up the conversation and break the taboo. If women do not reach out for professional help and medical advice, it can lead to delayed diagnosis and possibly a more severe condition. A recent study showed that 70% of women who experience a miscarriage would have some symptoms of PTSD because it isn't something many medical professionals are prepared to deal with. The rise of femtech brands should help break the cycle and end taboo thereby resulting in women's health no longer being on the sidelines, and ending the shame around women's health. Brands like Elvie (who caters to pelvic floor dysfunction and breastfeeding), Clue (menstrual cycle tracker), and Bayer (who specializes in menopause) all can break the taboo. Women who have been affected by underlying issues are included in the design process to ensure companies and products are catering to women's needs and are sensitive to their feelings. Implications: Because a taboo exists, sometimes even the most well-meaning medical professionals can find themselves under-informed and ill-prepared to offer practical solutions and support for sensitive women’s health issues. To break the taboo, women need to have the confidence to talk about their feelings and experiences to transform their overall health and wellbeing. Indeed, many businesses at the forefront of the femtech movement have been founded by women who have felt under-served by the traditional approach to healthcare which in and of itself should help the problem. They are providing support by creating more products and services they weren't able to access themselves and putting the needs of women at the forefront of design and user-experience. Investors have begun to recognize the importance of this sector and are slowly giving companies financial backing to help more women. These companies help close the care gap caused by shame and technology, making it easier for women to connect with healthcare professionals remotely and at their leisure. Technology can make it easier for women to connect with healthcare professionals from the comfort and emotional security of their own home. Consequently as noted by Ms. Chan, “this means it can be done anonymously, encouraging women to deal with conditions they may have previously avoided”. Moreover, femtech founded companies don’t just develop a product that solves a clinical problem, they also create brands that start a conversation which should elevate the discussions around women’s health issues and help reduce the stigma. How Femtech is Breaking the Taboo Around Women’s Health and Closing the Gender Health Gap

Enhancing Telemedicine Can Close The Infant and Maternal Mortality Gap Our Take: Increasing implementation of telemedicine in women’s pregnancy care has not only helped women during the COVID-19 pandemic but will also improve overall lagging maternal and infant morbidity and mortality rates in the U.S. According to the Commonwealth Fund, the U.S. maternal mortality rate is 17.4 per 100,000 pregnancies, ranking the U.S. last overall amongst industrialized countries. According to the CDC in 2018, the infant mortality rate was 5.7 deaths per 1,000 live births. This is especially important for minority women, who according to the CDC, are two to three times more likely to die from pregnancy related causes than White women and are also at a higher risk for hospitalization due to the Coronavirus. Increased adoption of telemedicine technology for prenatal and maternal care will help women and children of lower socioeconomic status who often lack access to healthcare services due to location, healthcare coverage, and other barriers. Some of the services offered via telemedicine include; video-conference routine visits, at home monitoring for at risk conditions like diabetes and hypertension, and phone/video consultation with specialists (high-risk obstetricians, lactation consultations, mental healthcare providers, etc.). The addition of this resource is a significant asset to maternal health and should contribute to the improvement in maternal and infant morbidity, specifically in the United States. Description: For many years, the United States has lagged other high-income countries in infant mortality statistics due to poor access to prenatal care, chronic disease, and cost barriers to healthcare access, particularly in underresourced communities. Increased use of virtual care in women’s health during COVID has exposed new avenues to deploy healthtech to increase women’s access to care. According to the Kaiser Family Foundation (KFF), routine pregnancies typically require 14 in person clinician visits when factoring in ultrasounds, lab tests, and vaccinations. For other periodic follow ups, patients in eligible states are given instructions and supplies to monitor the fetuses blood pressure, weight, fetal heart rate, and fundal height at home. These devices help maintain continuity of care with patient’s OB providers, while allowing patients to remain in their homes. According to a recent article by A. Bartley Britt, Chief Medical Officer of Fierce Healthcare, the maternal mortality crisis reflects an American healthcare system where comprehensive care is fragmented, face to face time with providers is short, and long-term care relationships are nonexistent. This prevents OBGYNs from developing the collaborative relationships with their patient’s primary care providers in a way that would help to understand their maternal health in a more comprehensive manner. By contrast, healthtech can overcome some of these problems by facilitating direct communication with providers. By giving patients the ability to message nurses and peers through available online platforms and downloading apps that provide pregnancy education, appointment reminders, and assist with insurance benefits and coverage information. All of these services help better educate patients and strengthen trust between them and their clinical teams. For example, according to the article, a study was conducted on the Due Date Plus app, a platform created by Wyoming Medicaid patients for direct nursing support. The study of 85 app users compared to 5000 nonusers found using phone applications was associated with lower risk of delivering a low-birth-weight infant and higher likelihood of completing prenatal care appointments. Telemedicine also fills a vital void for patients who need to travel long distances to receive care. In many rural communities, there is a shortage in healthcare specialists, particularly maternal-fetal medicine doctors, putting women experiencing high risk pregnancies at a severe disadvantage. With telemedicine, these patients have the ability to video conference with specialists, be evaluated remotely, and receive customized care management plans if necessary. These technologies also permit specialists to review ultrasound imaging performed by technicians conducting an exam on a patient in a remote location. Postpartum care is another key service offered. Typically, patients wait 6 weeks before their in-person postpartum doctor’s visits and up to 40% of women do not attend these visits at all. Fortunately, through the introduction of telehealth platforms, patients have access to app-based support, virtual communication with their providers, at home blood pressure monitoring, and can see a nurse practitioner at 1-week post-partum if enrolled in a program called MultiCare. The Medical University of South Carolina even offers behavioral health telemedicine visits for pregnant/postpartum patients in the area and the service accepts most insurance plans. Lastly, tele lactation services are offered for mother’s experiencing breastfeeding difficulties as well. Implications: The integration of women’s pregnancy resources onto telehealth platforms will greatly improve maternal and infant mortality outcomes. Although these resources are not as broadly deployed as they could be at this time, the lower costs and improved outcomes demonstrated by the technology should drive adoption going forward. In general these technologies help reduce the time and expense of travel and enable families to continue to tend to their other responsibilities without the inconvenience and cost associated with frequent visits. This should positively impact compliance as these are among patients major complaints when having to attend frequent doctor’s visits during pregnancy. In addition, as demonstrated during this pandemic, telemedicine also allows patients to have access to their physicians without having to put themselves at risk in healthcare facilities which can be pivotal for this high-risk population which must lower exposure risks. Instead of missing appointments or risking exposure, expecting mothers have access to their OBGYN’s from the comfort of their homes. As noted this is especially important for minority women, who are significantly more likely to die from pregnancy related causes than White women and who are at a higher risk for hospitalization due to the Coronavirus. Nevertheless, as noted in an article from the Kaiser Family Foundation entitled, Telemedicine and Pregnancy Care, while telemedicine access for maternal care is valuable many who need it still face limitations including: 1) Not having access to devices to connect their home to clinicians for monitoring due to high out of pocket cost, 2) Lack of reimbursement for telemedicine during pregnancy despite the ACA and Medicaid expansion programs that cover maternity costs, 3) Lack of coverage for pregnancy telemedicine services under private insurance plans without showing medical necessity, 4) Lack of internet access in certain low income and rural areas, 5) Lack of adoption in many struggling states. Clearly these issues need to be addressed if healthtech is to achieve its potential in improving maternal and infant mortality in the U.S. The technologies are not only useful in addressing rural-urban health disparities, but also improve access to specialists and mental health providers, enable home monitoring and improve the flow of communication between patients and their providers Telemedicine and Pregnancy Care; Maternal Mortality in the United States: A Primer ; Maternal & Infant Health, CDC Incorporating Digital Health Literacy as a Social Determinant of Health Event: Healthcare IT News recently reported on the importance of empowering patients with digital health literacy in order to allow them to take control of their own health data and close the digital health equity gap. During the event, Dr. Jorge Rodriguez, a health technology researcher and hospitalist at Brigham and Women’s Hospital, classified digital health literacy as a social determinant of health. Dr. Rodriguez along with other panelists, outlined five main facets that should be addressed when considering digital health equity: tech access, tech literacy, implementation, payment, and standard of care. A few recommendations were also given that can bring equity to patient-facing digital health tools. Description: The report reviewed the WEDI Quest for Health event, presented by the Workgroup for Electronic Data Interchange (WEDI) which investigated and showcased the significance data interoperability has to help eliminate healthcare disparities in the U.S. During the event a number of the speakers highlighted that the U.S. Department of Health and Human Services' recent finalizing of rules around the 21st Century Cures Act has highlighted questions about patients' ability to take control of their own health data. According to speakers at the event, not everyone has the same knowledge and level of self-determination to access digital healthcare. The article highlighted that approximately 21 million people in the U.S. lack broadband access or a physical device to seek digital health services. Rodriguez and his co-panelist, Dr. David Bates, General Internal Medicine Division Chief at Brigham & Women’s, stated that the five main facets that should be addressed when considering digital health equity are: tech access, tech literacy, implementation, payment, and standard of care. Dr. Rodriguez also made additional recommendations around ways to bring equity to patient-facing digital health tools. Those recommendations include: Classifying digital health literacy as a social determinant of health. Dr. Rodriguez advised providers and vendors to develop linguistically and culturally tailored digital health tools to engage diverse populations. Invest in patient portals and apps that address the needs of underserved populations. Track digital health access and usage across sociodemographics. Focus on patient training in the deployment of new technologies to account for varied digital literacy levels. Develop workflows that allow clinical teams to engage with diverse patients across digital health platforms. Clinical teams should offer all patients access to digital tools and encourage them to use those tools as part of standard care. Implications: According to speakers at the WEDI Quest for Health event, “digital health equity is essential for our success and the sustainability of digital health overall.” The novel Coronavirus crisis has highlighted the disparities and digital divide that continues to exist in accessing digital health. In addition, studies have shown that minority patients routinely receive inferior care because they may be bouncing between hospitals and clinics and also have higher rates of chronic illnesses like diabetes and hypertension, which research indicates can be better addressed by digital technologies. Having access to digital technology can empower consumers to make better-informed decisions about their health, provide new options for facilitating prevention, and manage chronic conditions outside of traditional health care settings. Addressing digital health literacy as a social determinant of health can bridge the gap in digital health within both rural and urban settings. Moreover, providing digital literacy to consumers will offer new ways to engage and serve medically complex and low-income populations that are often not well tracked by the healthcare system. This can significantly impact patient care and improve outcomes. Digital Health Literacy as a Social Determinant of Health Equity and Artificial Intelligence in Surgical Care Event: On February 24th the Journal of the American Medical Association (JAMA) published an opinion article about equity in the use of artificial intelligence (AI) for surgical care. The article reviews the disparities in surgical procedures and how AI holds the potential to both reduce and exacerbate disparities depending upon how it is used. Description: The use of AI in surgical care can exacerbate existing disparities if they are incorporated into models without discretion. For example, AI algorithms are trained and modeled on data sets, so if a data set which is used to train and perfect the model is biased then the resulting AI will be biased. AI models can legitimately incorporate racial composition of a sample population for an AI model, however, since racial composition may vary drastically from between geographic areas, the resulting AI could result in decisions that aren’t universally applicable. Similarly, if physician notes and their underlying experiences are input to the AI, any implicit bias from the physician's background and experience could be inadvertently incorporated into the AI. The authors note several studies referenced demonstrate bias in physician judgment across multiple demographic factors including, race, gender, and insurance type. This could introduce bias by including while potentially introducing inaccuracies into the models by intentionally excluding them. The authors conclude that for racial and ethnic data to be included in training and recommendation engines underlying AI they must be able to demonstrate causality. Interestingly the report also illustrates that while AI can exacerbate disparities, AI also holds the potential to counteract disparities in care if applied correctly. For example, in surgical settings, clinicians are often required to make high-stakes decisions virtually instantaneously. As a result, when faced with making a decision without sufficient time to assess a situation and thoroughly examine the factors before them, research in behavioral psychology has shown that humans will rely on prior knowledge and heuristics -psychological shortcuts formed from similar prior experiences. Unfortunately, this research has also established that such heuristics are also affected by bias. Consequently, AI models ability to rapidly incorporate large amounts of data could counter the bias in heuristic-based human inference and lead to more equitable decisions. Along these same lines, models that can incorporate representative data on patient-centered outcomes, such as those which integrate data around racial disparities in surgical procedure survival rates, can empower physicians with the ability to make more informed decisions with less bias. Implications: AI will likely be implemented in surgical care settings in the future at an increasing pace. It is essential that people applying any new procedures, technologies, and policies in health care keep the impact on equity in mind. As the article illustrates, there is evidence that disparities in surgical care exist and there is the opportunity to reduce their prevalence and magnitude using AI tools. However, if AI models are not examined, both pre and post development and their conclusions do not align with clinical intuition, the application of AI could result in unwanted results. In particular, poor application of AI could result in the worsening of already disparate allocation and outcomes of surgical care among differing ethnic and racial populations. As a result, data scientists and clinicians must undertake a coordinated effort to ensure the equity concerns are addressed when designing, training and testing such models. Equity and Artificial Intelligence in Surgical Care Going Digital with Healthcare Payments Will Improve Customer Experience Event: A recent article in MobiHealthNews presented three strategies for how organizations could keep up with the pace of digital transformation from Stuart Hanson who leads the Corporate Treasury Consulting and Healthcare Solutioning groups for J.P. Morgan (and a former chair of several HIMSS task forces). Mr. Hanson also provided innovative ideas to illustrate the strategies he recommends. Description: The COVID-19 pandemic reinforced the shift to more modern digital payment systems in the healthcare sector. Organizations have sought ways to deepen EHR integration to share patient healthcare data seamlessly across different platforms. The sudden shift to digital systems during COVID has accelerated the pace of change and forced organizations to consider longer-term strategies as patients are now expecting greater innovation. As consumers embrace greater use of clinical digital health technologies, these same organizations must adopt more innovative business strategies to keep up with consumer needs. According to Hanson, three strategies to keep in mind include: 1. Embracing digital patient engagement by prioritizing consumer-centric solutions that improve the patient experience. Hanson recommended creating a digital front door across all patient engagement points, providing easier access points like online self-scheduling, mobile pre-registration and check-in and electronic payments to name a few. 2. Expanding touchless and reduced-touch efforts by frequently disinfecting high-touch surfaces and limiting direct contact with shared surfaces for patients and employees. According to Hanson, touchless strategies can also extend outside of physical surroundings. For example, providers should take inventory on how many solutions and vendors are tied to financial transactions, and where possible reduce this number. 3. Focusing more on cybersecurity by having more robust controls and security measures that reduce the risk from ransomware attacks against payers, providers, and patients and protect PHI. Hanson recommended ensuring correct implementation of cybersecurity platforms that employ artificial intelligence, machine learning, and predictive analytics to help healthcare providers add additional security controls to protect critical data and secure payments. All three of the above strategies are a reflection of the increased use of digital technologies in healthcare and illustrate the need for innovative ideas that organizations can and should implement to keep up with the trend. Implications: Healthcare has long been viewed as ripe for digital innovation as demonstrated by rapid adoption and progression of telehealth with the onset of the pandemic. COVID-19 presented many challenges to the healthcare sector, such as adapting to new digital solutions, applying technology in innovative ways to keep people out of harm’s way and remain in positions to support additional growth. However, organizations may find it challenging to continue to embrace digitization due to concerns around continued sustainability of adoption and the need to invest in competing priorities for capital resulting from the financial toll of COVID on procedure volumes and margins. In addition, organizations have also been reticent to invest in new technology as consumers or partners have long been slow to adopt it in healthcare. Nevertheless, Hanson recommends that organizations must evolve with patient experience to meet the changing needs in an increasingly digital world by developing a consumer-centric healthcare landscape. While typically slow to adapt to technological change, the recent barrage of change in healthcare will not only create new opportunities to solve long-standing problems but it will also offer the opportunity to deliver new experiences that meet the expectations of today’s digitally native consumers. What Payers, Providers, and Patients can Gain from Going Digital with Healthcare Payments Video Telemedicine Usage Spikes Disproportionately for Higher Income and Higher-Educated Event: On March 4th Rock Health’s published it’s Digital Health Consumer Adoption Survey which revealed an increase in telehealth utilization and wearable usage. While the report revealed the increase in utilization was higher among the high earners (85% of responders earned a salary of over $150,000) and higher educated (86% with a graduate degree or higher) population there was a large drop in usage based on income or education. For example, only 65% of those with incomes between $35K-$75K and only 63% of those with incomes below $35K used telemedicine, while only about 60% or less with some college or no college used telemedicine. Description: Early on during the pandemic, telemedicine usage among patients fell with 60% fewer visits compared to the same period (March) of the previous year. However, as the pandemic took a peak, the uptick in live video telemedicine use rose from 32% in 2019 to 43% in 2020. The demographics using telehealth services were seen among those who were high earners and those with chronic conditions (78%) as opposed to those without a chronic condition (58%). The report also looked at telemedicine use by a number of demographic factors including age, sex, income, education, geography, as well as racial and ethnic groups. In terms of age, the report found that those 35-54 were most likely to use telemedicine while those 55 and older were least likely to use telemedicine, reporting a drop in utilization down to 59% (vs. 71% in 2020). In terms of sex, the report found that 74% of men were likely to use telemedicine, compared to only 66% of women, a drop of almost 11% points in utilization for women. Among income levels, as noted above, those earning $150K or more reported a utilization rate of 86% compared to 65% or less for all other groups. By education, those with a postgraduate degree or more reported utilization rates of almost 90% while utilization levels dropped to just under 70% for those with a bachelors or associates degree and approximately 60% or less for those who with no college degree or less. In terms of geographic differences in adoption, utilization was highest for those in urban areas, reaching almost 80% while dropping to just 60% for those in rural areas. Interestingly, Rock Health did not note a dramatic difference in adoption across different racial and ethnic groups but noted that a number of studies have noted different conclusions. We continue to believe there are significant differences by racial and ethnic groups (please see our blog post “Access to Telemedicine Is Hardest for Those Who Need It Most” link here) and "Health Inequalities in the Use of Telehealth in the United States in the Lens of COVID-19" (link below). Implications: The Rock Health Consumer Adoption survey found that telehealth users were heavily concentrated among the higher income brackets and among the educated, continuing a trend witnessed before the pandemic. However, given the increase in access that telehealth promotes (by eliminating commute time and the need to take leave from work) as well as the opportunity it provides for consumers to be active participants in managing their own health via wearable devices, remote monitoring, digital health broadening this access should be promoted. Increasing availability and ease of use of telemedicine would ensure that patients of all demographic groups are made aware of the benefits of this growing trend. The disparities in usage should be identified, and digital health innovators need to keep iterating and leaning in to uncover areas where adoption doesn’t match the potential for growth. Health care organizations need to reinforce and encourage making telehealth affordable, accessible to all and build confidence for consumers to want to utilize it. The regulatory reforms implemented during the pandemic last year, brought positive responses to the use of technology. Assuming many of these reforms can be made permanent or at least less challenging to implement, telehealth utilization would be more accessible to the general population and less disparities would be seen. In addition, with the cross-state licensure still in place, this platform also has the potential to give patients in underserved areas the ability to gain access to the best care across the nation at greater convenience and lower cost. Rock Health Digital Health Consumer Adoption Report 2020 & Health Inequalities in the Use of Telehealth in the United States in the Lens of COVID-19

Digital Technology Will Shift Care from Hospital to Home Our Take: The hospital of the future will provide flexibility to patients and providers by offering remote support through a digital infrastructure that can take the place of major health institutions, like hospitals. Healthcare organizations, particularly hospitals, can use remote monitoring to expand their scope of service and assure that patients are maintaining a healthy status. The integration of emerging technologies such as remote patient monitoring, telehealth, big data, advanced analytics, biosensors, and wearables will change how healthcare is delivered now and in the future. These technological innovations will improve operational efficiencies and clinical outcomes by eliminating the time and transportation issues that plague many underserved communities, empowering more convenient and cost-effective access. Over time this will facilitate more immediate and rigorous monitoring of at-risk patient populations, allowing them to become more engaged with their health and improve outcomes. Description: The digital transformation of patient monitoring makes it possible for clinicians to observe, report, and analyze patients' acute or chronic conditions, regardless of location, in real-time. Remote patient monitoring allows healthcare providers to longitudinally measure, monitor and capture health data from patients for assessment and feedback. Multiple studies have found that remote monitoring technologies have transformative potential to improve health care quality, safety, and care efficacy. A 2018 study conducted by JAMA Internal Medicine found that a hospital at home demonstration project had better outcomes than inpatient admissions. The study showed decreases in length of stay, 30-day readmission rates, emergency department visits, and skilled nursing facility admissions.[i] A growing list of organizations and institutions have been seeking scalable ways to provide remote, post-acute transitional, and value-based care within the home. A study conducted by IN-TIME showed that BIOTRONIK Home Monitoring enabled physicians to detect worsening heart failure at an early stage, facilitating early intervention and improving clinical outcomes. The study showed a 50% decrease in mortality for patients using this device and reduced hospitalization caused by atrial arrhythmias by 66%. Another entitled “Falls and Fall Injuries Among Adults Aged ≥65 Years - United States, 2014” looked at falls and fall injuries among adults 65 and over, the leading cause of fatal and nonfatal injuries for that cohort. The study concluded that approximately 20% of falls result in broken bones, head traumas, or other disruptive injuries that can double the chance of another fall in the future. According to the study, falls account for an emergency room visit every 11 seconds, lead to 2.8 million injuries per year and cost the healthcare system $50 billion per year (75% of which is paid by Medicare and Medicaid). Innovative digital companies are developing tools to address issues such as fall detection and in-home vital sign monitoring that could shift additional care safely out of facilities. For example, startups such as Safely You and Cherry Home offer wearables that can detect early indicators of falls, including low grip strength, hydration levels, and muscle mass, thus preventing falls and detecting signs from early on. In a study conducted at the University of Illinois College of Medicine at Urbana-Champaign, researchers evaluated the efficacy of wearable devices in fall detection and found it was about 73% accurate and had 81% precision. In patient monitoring Latitude NXT has developed an in-home, hands free, patient monitoring system that allows a healthcare team to monitor connected devices in-between primary care visits. While these companies and devices are only examples of the types of technologies being developed, all of which no doubt will need to be refined and perfected, they demonstrate the potential to shift care out of large, dedicated facilities like hospitals. Devices like these which send data to providers regularly collected from blood pressure monitors, pacemakers, cardiac monitors, weight scales, and other connected health devices allow continuous versus episodic or point-in-time diagnoses. Moreover, patient care networks like Merlin.net allow transmission of patient information to providers and enhance physician-patient relationships by giving them the ability to monitor patients and follow-up instantaneously. Implications: The speed and intensity of the COVID-19 pandemic has challenged us to reflect on what the hospital of the future will look like. Remote care technologies have been proven to enhance care delivery, improve patient outcomes, and contain costs for conditions that need constant surveillance. For example, 88% of healthcare providers have already invested in or are currently evaluating remote patient monitoring devices to implement in their current practice. Utilizing these digital outputs allows physicians and care teams to get real-time insights into a patient’s status by providing early intervention, avoidable hospitalizations, and trips to the emergency department (the costliest sight of care) . Enhanced remote monitoring technology can positively impact healthcare delivery by: 1) reducing patient stress and allowing patients to be treated from the comfort of their own homes; 2) limiting expensive and unnecessary visits, like ER visits; and, 3) reducing clinician burnout, eliminating unnecessary testing and improving diagnosis by giving them a more complete and accurate picture of their patients longitudinal health profile. A survey conducted by Musher showed that 77% of HR executives [respondents] saw telehealth as a permanent change. However, as the industry transforms from one that is facility-based to one that is more inexpensive, technologically based and consumer friendly, the industry must be conscious of how they use remote monitoring and virtual care technologies because there is a digital divide in low-income and under-resourced communities. If the healthcare delivery system of the future is to become one that is home-based, it requires patients to have access to wearables/sensors to track health outcomes, which means more investments have to be made into low-income and under-resourced communities to ensure broadband access. Additionally, it may require changes in incentives and reimbursement policies to ensure that patients are compliant in using the technology and are held reliable for their lifestyle choices. However, potentially many diagnostics and even procedures may be shifted away from facilities over time, and the hospital of the future will likely have a physically smaller footprint, digital tools will never eliminate the need for hospitals as they rely on algorithms and rules which cannot possibly capture all diagnoses or presentations of disease. In many cases the skill, intuition and experience of a physician will be needed, for as William Osler said, “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” Association of a Bundled Hospital-at-Home and 30-Day Post-acute Transitional Care Program With Clinical Outcomes and Patient Experiences; Forecasting the Long-Term Impact of Telemedicine; Falls and Fall Injuries Among Adults Aged ≥65 Years - United States, 2014 Walmart Slows Push into Healthcare Event: On February 19th, Business Insider reported Walmart’s alleged decision to slow down the roll out of 4,000 healthcare clinics by 2029. Walmart’s board of directors originally approved the plan to open healthcare clinics in 2018, backed by former Walmart CEO Greg Foran. Walmart’s integration into the healthcare realm put the company in the race with other retail giants such as Amazon, who recently successfully entered the market. The slowing down of the process could not only put Walmart behind in the shift to retail healthcare but could also deprive people of much needed healthcare resources given Walmart's focus on underserved markets where there are fewer options for care. Description: Walmart has a long history in healthcare, providing pharmacy services for over 40 years and filling over 400 million prescriptions a year. Walmart opened its first clinics in Georgia in 2018 with strong early results, as early clinic visits were double the health team’s expectations. The organization’s original timeline included opening 125 clinics by the end of 2021, 1,000 clinics by 2024, and 4,000 by 2029. Under its original strategy, Walmart clinics would offer several services including primary care at $40 with or without insurance, dental care, x-rays, hearing services, and mental health counseling. Considering the organization is the largest private-sector employer and the largest grocer in the U.S., its expansion into healthcare is a major play for the organization. While the company has already opened 20 standalone healthcare centers and plans to open at least 15 more this year, Business Insider reports the company is looking to slow down the roll out of the additional health clinics. The article states that with the replacement of key players who created the strategy behind the clinic rollout the original strategy is in question. According to eight former and current employees interviewed by Business Insider, in the wake of the pandemic the organization is choosing to focus on e-commerce. Additionally, Business Insider obtained documents that stated the company is not on track to meet its earlier projections for the number of clinics it wants to build this year. While some within the company are reported to be pleased about the change of pace because of the difficulty of entering the healthcare market, others are said to be frustrated about the departure from the initial goal that would provide inexpensive care for people in the U.S. Walmart has yet to comment on the rumors of a roll back but reassured its stakeholders they are committed to healthcare. Implications: While reports of Walmart’s decision to slow its healthcare expansion efforts remain unconfirmed, this decision impacts other tech giants including Amazon, Apple, Google and other non-traditional organizations who have attempted to broaden their healthcare efforts. Given Walmart’s trusted brand name, existing presence in pharmaceutical services, 3,400 vision centers, and $4 generic drugs, they are seen as having an advantage over other new entrants, however, if the rumors of the slow down are true many will point to how difficult it is to penetrate the healthcare market. For example, while Amazon has gained share in general retail from Walmart, and they have expanded their efforts in healthcare with the $750 million acquisition of the online pharmacy PillPack in 2018, they have decided to shutter the Haven joint venture please see “Inside the Collapse of a Disrupter: How Haven’s High Hopes of Redefining Health Care Came to a Crashing Halt”, link here). In addition, although competitor CVS began rolling out "Health Hub'' clinics in stores in early 2019 to provide health and wellness screenings and support for patients with chronic conditions, success of these efforts is still unclear. Nevertheless, the success of efforts by competitors like these, could put Walmart’s success at great risk if the organization’s new leadership does not push forward with their roll out plan or create a new strategy in healthcare. As the pandemic continues and more organizations are becoming sites for vaccinations, it is important that Walmart remains an active participant given its presence in communities with limited services and as a trusted provider. The question also remains whether this is a temporary fine-tuning of strategy or a more deliberate turn away from fulfilling their goal to be “America’s neighborhood health destination”. Should this end up being the latter, Walmart will join IBM and the Haven joint venture as emerging new entrants that have had difficulty cracking the healthcare puzzle. It will also underscore the importance of having a well-defined strategy, distinct goals, aligned interests and incentives, and a realistic timeline for a path to success. Walmart May Roll Back its Ambitious Push into Healthcare & Walmart is Slowing its Ambitious Push into Healthcare (subscription required) Top 10 Legal Considerations for AI in Healthcare Event: On February 16th, the National Law Review published an article from Katten Advisories, entitled “The Top Ten Legal Considerations for the Use and/or Development of Artificial Intelligence in Healthcare''. The article notes that given the dramatic rise in the use of artificial intelligence (AI) in health care companies have a number of new legal considerations that they should consider when using and developing AI for the industry. As illustrated by the title the authors believe there are 10 important issues that need to be considered and addressed in order to avoid liability or running afoul of the regulations. Description: According to the authors, below are the top 10 legal issues for AI in healthcare, not in order of importance. 1. Statutory, Regulatory, and Common Law Requirements: Depending on what roles the AI plays in care and treatment, state and Federal licensure laws may be triggered which could force the AI developer to seek licensure or other permits. 2. Ethical Considerations: Given AI’s potential role diagnosis and treatment protocols ethical issues around accountability, transparency, and consent may come into play. For example, clinicians must be able to explain to patients the factors and the process used for diagnostic decision-making by the AI involved. In addition, both legal and ethical accountability exists for any errors that might occur from decisions made by the AI. 3. Reimbursement Issues: With regard to reimbursement, there remains a question around how care provided by AI will be reimbursed and whether it will be covered by private insurers, Medicare or Medicaid, and/or potentially reimbursed at a lower rate if it is covered. Moreover, the article notes the potential issues raised when AI is used for administrative purposes including the risk that providers could be liable for false claims when billing errors occur. 4. Contractual Exposure: Whether developing AI as a solution provider or using an AI solution as a healthcare organization, it is important to have explicit contracts around the sale and use of AI technology. According to the article there are five areas in particular that need to be a focus, including: A) service level expectations which outline what specific performance metrics will be covered, B) representations and warranties that specify both which representations and warranties are going to be covered in the contract and the appropriate level of representations and warranties to be included from either a buyer or developers perspective, C) indemnification and specifically how any risk from AI technology will be allocated among the parties, D) insurance including what level of risk is going to be covered by the insurance, and, E) changes in the law specifying not only how contractual obligations will be impact by changes in the law, but also providing the flexibility to incorporate changes in the law into agreements. 5) Torts and Private Cases of Action: Both the developer and provider of AI services may have liability under existing tort law arising from AI. . As a result both the developer and provider must consider issues such as which party or parties will be liable for potential defects or unintended design hazards to consumers as potential liability associated with the AI itself. 6. Antitrust Issues: such as potential collusion in the pricing of AI algorithms by developers algorithmic collusion and price fixing are all targets for federal regulators. Operators should be careful to avoid engaging in market controlling behavior in the development of AI tools or in sharing of the datasets used to create or train them. 7. Employment and Labor Considerations: While AI has the potential to streamline practices like hiring, given that AI will likely impact employer policies and training methods it could also create potential liability under employment law. For example, integration of AI into the workforce could potentially create biases and lead to employment discrimination actions. 8. Privacy and Security Risks : Privacy and data security concerns in healthcare are only heightened due to the massive amount of data necessary in the development and use of AI. This creates many avenues for potential disclosures and breaches of applicable healthcare regulations like HIPAA, GDPR and CCPA. 9. Intellectual Property Considerations: Developers of AI will need to ensure they protect their intellectual property rights for their AI and what rights they may have for AI which they have licensed. In addition, it is important to specify agreements around who owns the data and any liabilities connected to that ownership. 10. Compliance Program Implications: Given AI is generally not static, both users and developers must constantly monitor compliance policies and procedures to make certain they keep pace with AI tools as they evolve. Also, it is crucial to make sure proper training and procedures are in place so that employees using AI technology are adequately trained. Implications: As the role of AI in healthcare expands, developers and providers must pay close attention to these issues and changes in legislation and regulations around them. Those who use healthcare data whether in practice or in the creation of products for others must ensure they have a plan for what data will be needed and how it will be used early on in the process. Moreover, data scientists and developers should consider the need for early review and intervention by legal and regulatory experts in order to avoid more expensive interventions further down the road when products may be more fully developed and harder to change. Innovative companies will have to balance the need for speed to market against the time to analyze and evaluate the product for it’s potential to inadvertently or unintentionally run afoul of existing standards. Failure to address the legal ramifications of new technology, particularly for tools as groundbreaking and controversial as AI could not only slow development, it could potentially kill a product. Top Ten Legal Considerations for Use and/or Development of Artificial Intelligence in Health Care Telehealth Must be User-Friendly to Be Effective Event: Healthcare IT News reported how St. Thomas Community Health Center in New Orleans had to switch telehealth vendors largely because its patient demographic which consisted of an older, African American, Medicaid eligible population, had little or no Internet access, lacked experience using mobile technology, and found it difficult to use. According to the article the center had tried to use its existing telehealth platform, doxy.me, to reach patients but found the technology was extremely challenging and added more anxiety to an already stressful situation. Description: According to the article, the then-current doxy.me platform St. Thomas was using created challenges preventing the staff from getting the results needed to address patients’ needs. Instead turned to Sano Health to tackle the challenge. It noted that St. Thomas and Sano identified the underlying issues on both the provider and patient’s end and provided a customized solution that would cater to St. Thomas’s specific patient population. Instead of having multiple apps/options on the home-screen, Sano Health provided a solution; easy-to-hold, easy-to-use Sano devices. This allowed the simplest access to doxy.me telehealth via text option, voice calling, and MyHealthRecord EHR. Moreover, the provider’s have the capability to monitor the devices’ use. Using that information St. Thomas can refine and improve the product for their patients and monitor the success of the joint collaboration. In the words of the CEO of St. Thomas, “Within a few months of distributing the first 400 devices, we were able to conduct approximately 900 audio/visual visits that would otherwise not have happened due to technical limitations. In addition, these devices have been an important tool in addressing social isolation among seniors." Implications: During the pandemic, the use of telehealth skyrocketed but not all organizations’ telehealth platforms have been effective. As this example demonstrates, providers need to strategically evaluate both telehealth technologies and the specific demographic, technological and physical capabilities of their patient population to ensure a fit between the two. If, for some reason there is a mismatch, hospitals need to take initiative and act in a timely manner to restructure their platform to ensure they’re reaching their patient in an appropriate fashion. Choosing the correct platform and building it according to the ease of use for patients is a process. Organizations must be well trained and educated to ensure the platform has been designed or implemented in the simplest, most understandable, and accessible manner, to meet the needs of all patients. For example, looking to make the process more user friendly, St. Thomas and Sano Health came up with video tutorials for the “how-to-guides” which were more effective and efficient than walking patients through the step-by-step process. Moreover, while the providers or vendors can ensure that the technology works as planned they also need to consider working with local governments and nonprofits to ensure patients have broadband access so the service is actually functional in the areas where patients live. Health Center Customizes Telehealth Mobile Device that's Easy to Use for the Elderly

Our Take: Telehealth Could Magnify Inequity For Those Who Lack Access Event: While telehealth has helped bridge communication gaps, allowed for the continuation of care and reduced patient and clinician exposure to the coronavirus, some long standing barriers still must be addressed to improve the effectiveness of telehealth. Not only are high-speed internet lines scarce in rural areas, but the cost of broadband is out of reach for many families. While efforts have been made to broaden laptop distribution in under resourced communities for education, which we see as analogous to healthcare, many low-income students still lack them and high-speed access to use them effectively. Description: Rural Americans are 10 times more likely to lack broadband access than their urban counterparts. In 2018, the Federal Communications Commission (FCC) estimated that one-quarter of rural Americans-and one-third of Americans living on tribal lands-did not have access to broadband (defined as download speeds of at least 25 megabits per second). By comparison, less than 2 percent of urban Americans lacked that same access. The lack of broadband in rural areas is a prominent inequality in US society. While this impediment is applicable in rural areas, cost is an issue for low-income families everywhere, especially in large urban areas. Broadband service can cost up to $349.95 a month in California and up to $299.95 in parts of Alaska, Kentucky, and Virginia, according to data from BroadbandNow.com. Due to the lack of broadband availability and affordability, tens of millions of Americans aren’t able to “see” their doctor over the internet in the same way a majority of Americans can. The lack of broadband access in a time when social distancing is highly encouraged may have created additional health disparities for patients in rural areas. Research has shown that areas with limited broadband access also had higher rates of chronic diseases such as obesity and diabetes, resulting in "a double burden where those with the lowest connectivity have the highest need." To overcome this issue, the hospital system has started to offer visits via telephone instead of online, which is even more limiting. A rural hospital system in northern Michigan responded to a statewide stay-at-home order issued March 23 by implementing several telehealth measures. These included using telehealth in COVID-designated inpatient hospital rooms to improve communication between clinicians, allowing health care workers to work remotely to limit exposure, and implementing telehealth services at long-term care sites. While only 3% of residents in Michigan's urban areas do not have access to high-speed broadband internet, about In addition, merely having broadband access will not solve all problems. Even for people in rural and urban environments, who may have access through a WiFi hotspot, that access and throughput may not be fast enough for what is needed. For example, many who lack wired broadband have smartphone access but access via a smartphone will not suffice. As noted by the Benton Institute “mobile broadband is not a substitute for a fixed connection. 4G service (which provides the speed necessary to stream video) is not universally available, and most phones come with either data caps or data throttling. [In addition] data caps become more severe if trying to turn a phone into a ‘hotspot’ to connect other devices, like laptops and desktop computers or smart TV’s”. Lastly, broadband is not just about telehealth which may impact an individual’s health directly, but also about services which may impact the other social determinants of health. The pandemic has also required people to go to school and work from home where lack of access could impact finances, or lead to stress and isolation. Approximately 10 to 16 million students in the US lacked internet access before schools shut down and since that time only about 3 to 4 million students have received at-home internet access.40% of people in the state's rural areas lack such access. Implications: Identifying other barriers to the use of telehealth and evaluating patient outcomes are also essential. The digital divide is a multifaceted and complicated problem to solve. It can involve lack of access to or affordability of a device capable of high speed connectivity, consistent access to high-speed WiFi itself (vs. inconsistent access through a shared hot spot), cost of access and often more than one of these issues at a time. Even when families have limited access to WiFi through a shared hotspot via a smartphone or community hotspot, speeds will often not support online video required for synchronous video visits and disconnection is common. Broadband and device accessibility has become a public health priority and the government must respond urgently. When providing help for these communities, we must be asking more complex questions about their home life to offer appropriate help. According to the authors of a 2015 study on rural broadband expansion, “While the vast majority of federal programs dealing with broadband have focused on the provision of infrastructure [i.e., broadband supply], many economists and others involved in the debate have argued that the emphasis should instead be on increasing demand in the areas that are lagging behind.” Moreover, according to the Benton Institute for Broadband & Society, while the government has focused on supply, efforts may be more appropriately aimed at the demand side. For example, according to the Institute, the least dense areas of the United States pay upwards of 37% more for broadband than the densest centers with the lowest-income households tending not to have a home broadband subscription, citing price as the problem”. Importantly this could lead to an exacerbation or racial disparities in rural populations which are showing patterns of increases in BIPOC populations. In 1990, one in seven people in rural areas identified as people of color or indigenous, in 2010 one in five rural Americans identified this way. The 2020 census will likely reflect an even higher number. Although the first COVID relief package passed by Congress in the spring neither addressed nor allocated money to fix the broadband issue, the most recent $900 billion relief package passed in December includes up to $50 a month for low-income families to pay for broadband. However, that amount falls well short of the costs of broadband in many areas. As we have noted in the past a more concerted and coordinated response is needed, perhaps involving community partnerships among educators, payors and providers. This is crucially important as research has demonstrated that lack of access impacts educational attainment which is shown to have a direct impact on economic success and health disparities. For example, as noted in a 2018 article in BMC Public health “several studies have demonstrated that educational level is a key determinant of health disparities in later life among other aspects of health, including mortality, disability, frailty, chronic diseases, mental health…” Clearly, addressing broadband access for its role in providing greater support to digital tools as well as other elements of social disparities of health (SDOH) must be a primary concern for all elements of the healthcare ecosystem. Too Many Rural Americans Are Living In the Digital Dark. The Problem Demands A New Deal Solution; Study Examines Telehealth, Rural Disparities in Pandemic; Cost of Connectivity-Infographic Mobile Health Apps Systemically Expose PII and PHI Through APIs Event: On February 9th, BusinessWire reported the results of a study “All That We Let In,” conducted by cybersecurity marketing firm Knight Ink which examined 30 mobile health apps. The study, done for mobile app Application Programming Interface (API) security company Approov, found that all apps were vulnerable to API attacks and could lead to the exposure of users’ sensitive health and identity information. Description: Researchers reverse engineered 30 mobile health apps by using an open-source security framework, analyzed their static code, and then penetration tested their APIs. The study found that of the 30 apps tested, 77% contained hardcoded API which are API keys embedded via plain text (non-encrypted) into source code there by exposing credentials (account passwords, SSH Keys, DevOps secrets, etc.) to hackers and potentially creating a backdoor accessway to an application. In addition researchers found that of the 77% of hardcoded API keys, almost 10% of those belonged to third party payment processors that specifically warn against hard coding API keys in their documentation. Moreover, the study found that out of the API endpoints tested, 100% were vulnerable to what is known as a Broken Object Level Authorization (BOLA) attack where attackers substitute the ID of their own device in the API call with an ID of a device belonging to another user which exposes sensitive data such as full patient records, lab results, and other personally identifiable information (PII) including birthdates and social security numbers. The report did not disclose the names of the tested apps or developers but noted that they are from international healthcare information technology companies with revenues ranging from $600 million to $8 billion, with an average employee count of about 15,000. Implications: Cybersecurity is a growing concern for healthcare organizations and continues to threaten the mobile health space. While many consumer-facing apps have found themselves in the news for exposing user information or undisclosed third-party data sharing, the dramatic increase in the use of mobile health apps during the pandemic has heightened the security risks. The report noted that such vulnerabilities suggest that security measures required for FHIR/SMART compliance need to be addressed to secure both the mobile apps and the APIs that enable apps to retrieve data and interoperate with data resources and other applications. Although the authors expect that there will always be vulnerabilities in code so long as humans write it, they did not anticipate that 100% of apps tested would have an issue. This exposes a systemic problem. The report went on to recommend several steps that mHealth platform developers can adopt to address concerns, protect user data and sensitive resources including: 1) addressing both app security and API security; 2) securing the development process and hardening apps; 3) protecting against middle attacks by using certificate pinning; 4) improving visibility to controls; and, 5) performing penetration testing and static/dynamic code analysis regularly. Mobile Health Apps Systematically Expose PII and PHI Through APIs, New Findings from Knight Ink and Approov Show & Report: All That We Let In The Broken Promise that Undermines Human Genome Research Event: A recent article in the journal Nature described how the promise and prospect of unfettered data sharing envisioned by the Human Genome Project (HGP) almost 20 years ago, has devolved into a patchwork of repositories, with various rules for access, and no standard for data formatting which one of the creators characterized as a “Tower of Babel”. The article points out that despite laying out what became known as the “Bermuda Principles'' whereby all parties agreed to make all human genome sequences immediately available in public databases within 24 hours, with no delays or exceptions, this has been far from the case in practice. Description: Prior to the efforts of the HGP to standardize data practices “there had not been a serious discussion about data sharing in biomedical research”. As the article highlights, each data would do their own research and hang on to their own data for as long as possible. The goal of the (HGP) and the Bermuda Principles was to change that. The idea, later adopted by academic journals and grant funding agencies, meant that anyone would be given access to data created for published genomic studies in order to use them to attempt new investigations. However, although all of the parties had agreed to immediate and open access of information, it has not worked that way in practice. One problem is that since most individual level genomic data include phenotype data, that can include health-care records, disease status or lifestyle choices they must reside in what are known as “controlled-access databases”. This provides a layer of protection from the legal and ethical issues that come with identifying the data, as even anonymized or de identified data can at least theoretically be reidentified. To avoid legal and ethical issues, controlled-access databases are used to ensure that the data in question are only being used for their specific purpose. However, uploading data into these databases is often cumbersome and time consuming often resulting in only the information required to be compliant being uploaded, leading to minimal and sparse data. In addition, the required genomic information can be stored in more than one repository, making data collection “unnecessarily difficult”. Some have complained that “even logging into [one of the genomic databases] can be a pain” leading them to look for workarounds. Even researchers who are willing to wade through these issues find that they often come up with little for their efforts. One researcher noted she had spent 6 months filing the requisite papers to get what she thought was a publicly available dataset on a research institute's portal, only to find out it wasn’t publicly available. Implications: The article highlights the difficulty of data access, data sharing and data-interoperability in healthcare. The HGP is a stark example of the pitfalls involved even after standards and agreements are in place. In addition, it crystallized the need for those dealing with data to have clear plans around the need for and use of any healthcare data they plan to obtain in the course of using or marketing their products to the healthcare ecosystem. Moreover, it demonstrates the need for marketers and researchers to understand and anticipate the many hurdles they may have to overcome, both regulatory and procedural in implementing their solutions. While new rules around data interoperability and data blocking should begin to improve the flow of data, it will take considerable time to dramatically ease the flow of data and information within healthcare organizations. The Broken Promise that Undermines Human Genome Research Vaccine Distribution--Equity Left Behind? Event: Recently JAMA published an editorial espousing the opinion that a shift in vaccine distribution priorities in some states could exacerbate health disparities. As the article noted, many states have recently shifted their vaccine distribution plans by prioritizing people 65 or older instead of following the CDC’s original prioritization factors such as high-risk medical conditions, occupational exposure for essential workers, and other societal needs. According to JAMA, this change in approach to distribution of the vaccines has raised concerns over equity of this method. Description: Intricate plans that have taken into consideration varied criteria for vaccine distribution eligibility have been criticized as slowing the rollout with complications. People age 65 and over count for greater than 80% of COVID deaths in the U.S. The arguments in favor of the strategy suggest that it is a simple way to bring the vaccine to the people it will benefit the most. However, JAMA believes that implementing it on its face with no consideration for health equity will lead to greater disparities. Making an appointment for a vaccine dose is a time consuming process that requires technology and trust in a system of care which is lacking in underserved communities. The pandemic has exposed the severity of health disparities in the U.S., with low-income people and communities of color disproportionately affected. While the rollout of vaccines based solely on age has begun, the article suggests localities can take steps to ensure health equity remains part of the equation. Entities can prioritize vaccine distribution in zip codes most affected by the infection of the virus and economic hardship of the pandemic. They can also partner with local health care institutions, community organizations, and other entities trusted by populations who have been the most affected by the virus to promote vaccine awareness and uptake. Steps can be taken to prioritize vaccine distribution to people with mobility and transportation issues or disabilities, such as shuttle services, choosing vaccination sites near public transit, and flexible operating hours for those who have difficult work schedules. Additionally, equity could be greatly improved by simplifying registration procedures. It is important to employ methods that do not rely on digital technology for those with low computer literacy, to ensure registration forms are available for those with limited or no English proficiency, that they do not require unnecessary documentation, and that they do not require pre registration that relies on knowledge of a set schedule and planning ahead. Implications: The JAMA article highlights the growing shift to only prioritizing COVID vaccine distribution based on age may be troubling for the health equity of the vaccines. Low-income people and communities of color have experienced higher rates of infections and deaths than their counterparts, and while the disparity was predictable for anyone familiar with the U.S. health landscape, it is unacceptable that little has been done to combat it, according to JAMA. The shift in vaccine rollout plans mean more opportunity for inequities to grow, making measures to ensure equity is not left behind essential. Vaccine Distribution—Equity Left Behind? New mHealth Study Gives Kids a Chance to Learn From Video Games Event: mHealthIntelligence recently reported on the launch of Magellan Health’s new study created to determine how mHealth games can help children with mental health concerns. With the push to stay indoors during these unprecedented times, mental and behavioral health concerns have reached new heights, causing researchers to explore innovative options to combat these issues in the most efficient way possible. Description: According to the article, studies have shown that the COVID pandemic has caused an uptick in mental health issues among children across the U.S. Children are now forced to be isolated indoors and have less human interaction and care. As a result, Magellan Health, an Arizona- based managed care company partnered with Mightier, a Boston based video game developer that did research at Boston Children’s hospital and Harvard Medical School using video games, to find a solution to address this growing issue. According to Matthew Miller, senior vice president of behavioral health for Magellan Healthcare, the study’s goal is to reaffirm the idea that digital tools like Mightier can improve health outcomes, lower the cost of care, and increase access to mental healthcare, especially during a time when the availability of a vaccines, stress, and anxiety continues to loom and the availability of in person mental health services is minimal. Implications: With the implementation of this tool, children will now have easier access to tools to help with emotional regulation, which serves as a pivotal weapon to combat stress and symptoms of many common mental health disorders. According to the article, clinical trials conducted at Boston Children’s Hospital and Harvard Medical School over the past few years have produced video games that have helped children reduce emotional outbursts by 62%, oppositional behavior by 40% over 12 weeks and reduced family stress by 20%. In addition, given the uncertainty surrounding when the pandemic will end, it is important to create solutions that will immediately aid children and families dealing with these issues. This is especially important for children in rural communities, who already had limited access to specialty resources prior to the pandemic. If the widespread implementation of these solutions yields positive results, this could potentially be used to combat other health issues amongst children, improving outcomes in an easy to access and cost-effective manner. New mHealth Study Gives Kids a Chance to Learn From Video Games

5 Ways to Make Sure Your Employees are Okay Event: On November 12th, Benefits Pro released an article advising five ways employers can make sure their employees can successfully navigate the stressor caused by the COVID pandemic. With millions of people affected by the Virus, Benefits Pro reminds employers not to overlook the toll it can take on the mental health of their employees. Description: With all of the virus' stressors, U.S. workers are experiencing higher than average levels of mental health issues during the pandemic. While HR and employee relations teams would normally want to step in and help, working remotely makes it difficult to identify exactly who needs assistance. As such, advisers suggest five strategies on how to read between the lines and offer support to employees who may be struggling.1) Set up frequent touchpoints-connect frequently with employees both in team meetings and one-on-one which will allow employers a chance to assess how people are doing. 2) Use analytics to read between the lines-look for anomalies like significant reductions or massive increases in productivity. Either could signal employees are struggling. 3) Understand that women may face more hurdles than men so they may necessitate special focus. Research from CARE indicates COVID-19 is having a disproportionate impact on women, with Mothers, senior-level women and black women particularly at risk. 4) Make sure employees are aware of resources offered. Be proactive and remind employees of your benefits and ensure that furloughed employees are aware of any extensions of mental health benefits (if offered). 5) Share personal experiences to destigmatize mental health issues. For example, invite a C-level executive to share their experiences with employees so people who are struggling know they’re not alone. Implications: Remaining productive and focused at work is challenging for many employees given pandemic induced stress of being isolated while working from home, balancing work and home-schooling, taking care of vulnerable loved ones, and more. As a result Employers need to be taking additional steps to proactively uncover mental health issues that may be brewing below the surface before problems become more serious. Given experts like Dr. Fauci don’t expect life to return to “some degree of normality” until late 2021 [even with a vaccine] employers will likely need to evaluate and strengthen the breadth and depth of their mental health offerings and the visibility of those offerings, at least for the foreseeable future. 5 Ways to Make Sure Your Employees are Okay Patient Experience Better When Patients Visit Docs of Same Race Event: On November 11th, PatientEngagementHIT released a study conducted by the Perelman School of Medicine at the University of Pennsylvania, addressing the correlation between patient experience scores and the race of both patient and doctor. In addition, the study looked at the need for health systems to address racial implicit bias in medical settings. The study concluded that patient experience scores tend to be at their highest when a patient sees a physician of the same race and that health systems must do a better job at addressing implicit racial bias in medical settings. Description: The researchers looked at approximately 120,000 patient experience scores for an urban academic medical center, focusing on the “likelihood to recommend” domain. The study found that patients who saw physicians of their own race or ethnicity were more likely to rate their physicians higher on patient experience surveys than those who saw physicians of a different race or ethnicity. Although the differences in rating seems small, with black patient’s rating white physicians 0.03 points lower on “likelihood to recommend” than their rating for black physicians, that 0.03 points difference could lower a physicians mean score on Press Gainey ratings from the 100th percentile to the 70th percentile. Implications: The results of the study reiterate the association between race/ethnicity and patient-physician interaction/ outcomes and the implicit racial bias black patients have experienced in healthcare. This ultimately impacts healthcare delivery, health disparities, and morbidity and mortality rates amongst African Americans. The results serve as a warning for healthcare organizations, especially those that may rely heavily on patient experience scores for compensating physicians, and that addressing the needs of their patients from a culturally diverse perspective is crucial. The study reinforces the belief that cultural competency and efforts to address implicit bias in healthcare is essential as is the need to understand/pay attention to non-verbal social cues. Patient Experience Better When Patients Visit Docs of Same Race FDA Releases Final Guidance on Clinical Trial Diversity Event: On November 9th, the FDA finalized guidance for promoting diversity in clinical drug studies and released its report “Enhancing the Diversity of Clinical Trial Populations--Eligibility Criteria, Enrollment Practices, and Trial Designs Guidance for Industry ''. The guidance considers both demographic considerations (ex: sex, race, ethnicity, age, location of residence) and non-demographic characteristics (ex: comorbid conditions, disabilities, those at extremes of weight range, etc) of populations. Description: The FDA’s 21 page guidance includes recommendations on how clinical trial teams can widen eligibility and enrollment groups for those historically underrepresented in trials such as the Black and Latinx community, pregnant women and those with certain physical conditions. Recommendations include, broadening eligibility criteria to increase diversity by among other things, requiring fewer exclusions related to concomitant medications (prescriptions or OTC drugs/supplements that may cause side effects) or comorbidities as more data on drug metabolism and drug-drug side-effects becomes known. In addition, the guidance suggest sponsors should make more effort to enroll participants who reflect the characteristics of clinically relevant populations with regard to age, sex, race and ethnicity stating that sponsors should include an “inclusion plan” no later than the “end of the Phase 2 meeting”. The guidance also states that sponsors should look at trial design and methodological approaches such as adaptive trial design and enrichment to broaden participation. Implications: The guidance clearly raises the bar for sponsors to be more proactive in trial design and recruitment so that they can “endeavor to include diverse populations to understand …risks and benefits [of medical products] across all groups. In the guidance the FDA made clear that sponsors will be responsible for taking additional steps including offering and making patients aware of financial reimbursements for expenses associated with costs incurred to participate in trials. In addition, study designers are going to have to ensure that they incorporate ways to reduce the frequency of clinic visits for elderly and disabled by using digital tools like electronic informed consent, telehealth and remote blood pressure monitors to replace or supplement in-person visits as well as mobile medical professionals (ex: nurses and phlebotomists) when that isn’t possible. Finally, the guidance notes that to broaden participation sponsors will have to engage underserved populations earlier in the drug development process and work more closely with communities through outreach and public education efforts to assess trial participant needs and drive higher support. FDA Releases Final Guidance on Clinical Trial Diversity & FDA Guidance Trial Diversity Designing Better Tech for Seniors Means Simplifying Tech for Everyone Event: A recent article in Mobihealthnews noted that many caregivers have turned towards technology and digital health solutions to keep older adults healthy and independent. A recent report from Rock Health highlighted that 77% of people over the age of 55 say they want to age in place, and only 50% believe they will because of barriers such as home maintenance, lack of transportation and mobility, inadequate preparation, and age-related accessibility. Description: Since 2010, the 65-and-older population has grown by over a third and by 2030, one in every five Americans will be of retirement age. As the demographics of the U.S. age, many caregivers have turned towards technology and digital health solutions as ways to keep older adults healthy and independent. In addition, according to a recent study, more than 60% of Medicare-eligible seniors say they’ve embraced technology more during the pandemic. Consequently. tech developers need to create products targeted at older adults that are designed to help them age and stay independent without stigmatizing them. Digital technology for seniors should be created with the P’s in mind – purpose, people, and possibilities. Technology built with a purpose makes seniors feel useful in society and their communities. It is associated with fewer heart attacks, better sleep, lower stress hormones, better immune system, and lower healthcare costs. Using digital health technology to connect with people can reduce isolation, affecting about 25% of adults over the age of 65. Isolation and loneliness lead to higher blood pressure risks, heart disease, obesity, a weakened immune system, anxiety, depression, and even death. Implications: As time progresses, technology is evolving and will outpace the ability to keep up with it. Barriers that keep seniors from using technology include a lack of instructional guidance on using it, a gap in knowledge, poor eyesight and hearing, and cost. Designing technology for everyone means creating customization features for smaller populations critical in making better solutions for seniors while remaining usable for everyone. Digital health technology should be customized to ease and assist seniors in their daily living activities while being in full control of their health. With a disproportionate share of COVID deaths occurring in senior care facilities, more older Americans are likely to want to live independently longer and the design of technology will need to keep pace. If it does, with the increased application of technology, seniors can decrease loneliness and experience better mental and physical health for longer periods without needing to be cared for in an institutional setting thus saving costs and improving quality of care and quality of life. Designing Better Tech for Seniors Means Simplifying Tech for Everyone From Today to Telemedicine: 3 Gaps and Risks Event: A recent article from Healthcare Dive pointed out the growing trends in telemedicine since the pandemic, and its usefulness for patients who live in remote areas and especially for those who are elderly and/or otherwise at high risk for contracting COVID. However, while the healthcare industry makes the case for greater use of telemedicine, 3 key risks and gaps were identified that must be addressed for it to be a vital and enduring component of virtual care. Description: As COVID hit, face-to-face office visits dropped, and telemedicine took a sharp rise (tenfold increase). If telemedicine is here to stay for the long run, there are 3 identified risks/gaps to be addressed: 1) Health Care Providers (HCPs) need to be comfortable with telehealth technology-among 1700 physicians surveyed in June only half were comfortable with the current technology, 2) HCPs need tools for going beyond “superficial” observations. Using current technology providers may be able to spot the usual but miss the unusual leading to potential misdiagnosis or medical errors, 3) Policies need to support telemedicine-COVID prompted temporary relief with reimbursement in telemedicine visits, however, until there are comprehensive reimbursement policies, it is likely to still have gaps in telemedicine availability. Implications: The pandemic has had a tremendous positive impact on telemedicine; it has allowed patients to accept this new platform of care. This method of delivery of care is highly dependent on physicians. Thus physicians must wholeheartedly embrace the new technology and must be responsive. As digital health tools become more widely deployed, additional tools and product development are going to be required to ensure proper remote diagnosis (ex: IoT sensors, bluetooth enabled diagnostic devices, etc.). While a number of regulatory hurdles were quickly set aside during the pandemic, regulators, payers and providers will have to reassess the ecosystem to bring policies and regulations up to date with the years of progress gained in only the last 8-9 months. From Today to Telemedicine: 3 Gaps and Risks Clashing Studies Highlight a Digital Health Void Event: On November 11th, STAT HealthTech released an article reviewing sharply contradictory studies on a new product from Pear Therapeutics. The new product is reSET-O, a prescription digital therapeutic that uses software to deliver cognitive behavioral therapy to patients with opioid use disorder. Description: While a study from Expert Review of Pharmacoeconomics & Outcomes Research showed that Pear Therapeutics reduced hospital stays, emergency department visits, and other care in a group of 351 patients, another study from the Institute for Clinical Economic Review presented that reSET-O would actually increase costs by $1,400 over a five-year period compared to the current standard of care. Surprisingly, neither study is necessarily wrong. Each study evaluated the product based on different sets of information over varying time periods.As noted by the Digital Therapeutics Alliance, digital therapeutics rely on high quality software to deliver evidence-based interventions to patients to prevent, manage, or treat disease…[and] can be used independently or in concert with medications, devices, or other therapies to optimize patient care and health outcomes.” As such evaluating their effectiveness involves an entirely different regulatory approach than current therapies. Implications: The different results from the two studies show that further research and clear evidentiary standards are needed to evaluate digital therapies and services. If conclusions remain conflicted, these products will remain mired in confusion. In addition, without clear standards the category could remain susceptible to fraudulent products or claims. As such, it is incumbent on the industry and trade groups such as the Digital Therapeutics Alliance to develop widely accepted, transparent and reproducible standards of effectiveness. Clashing Studies Highlight a Digital Health Void (STAT HealthTech-Subscription Required)

FDA Patient Engagement Advisory Committee (PEAC) Meeting on Adaptive AI and ML Event: (10/22) On October 22nd, the FDA Patient Engagement Advisory Committee (PEAC) held a meeting to discuss complex issues surrounding Artificial Intelligence (AI) and Machine Learning in Medical Devices. Attendees included several patients, companies, clinicians, and other high-level leaders. The meeting was centered on issues around the medical devices, its regulation, and usage by patients, in addition to their concerns on data privacy and transparency. The committee made recommendations on improving AI and machine learning in medical devices by giving careful consideration to datasets and how it can be used to train and improve algorithms. Adaptive AI presents new challenges for patients, companies, and regulators regarding informed consent, considering where the device would learn algorithms, use algorithms to improve decision-making, and make advanced improvements moving forward. Description: AI technology will be used to improve diagnosis and make recommendations for a course of treatment. Using adaptive AI will allow machines to learn more freely and improve what it learns from each sequence it is running. For future AI models to be successful, there must be a diverse representation in the intended patient population's data. Diverse and unbiased patient cohorts will allow for less biased data and remove clinical variables that lead to AI devices' mistakes. When data is not present for certain groups in a population, AI researchers cannot study them and find ways to combat societal issues. Incorporating and collaborating with patients in the creation of AI technologies will provide transparency and confidence in the products; however, many barriers exist even after a product makes it to market because criteria can change over the device's life. Adaptive AI makes decisions dependent on the life it sees out there – an apparent reason why it must be regulated because devices should differentiate between good and bad decisions to ensure safe outcomes. The committee struggled with a decision on how to explain the challenges of how explainability and transparency in AI models can be presented to patients. Implications: Large clinical datasets can be used to train and improve AI algorithms, leading to immense improvements in AI-based systems that diagnose as well as those that determine treatment protocols and actually treat patients. AI technologies will change clinician workflow and ensure continuous safety and efficacy in delivering ongoing quality care to patients.However, because ML algorithms can “learn” and “change” over time, medical diagnoses and treatment can change as adaptive AI models change as well, raising ethical concerns around transparency and informed consent. In addition, adaptive AI models also suffer from the shortcoming of biased training sets and under representation of underserved communities. As a result, patients and regulators need the ability to understand and examine models too so that the risks and consequences of any changes to treatment protocols due to improvements in the models can be assessed. In addition, the committee appeared to strongly imply that new informed consent releases would be required when changes to AI algorithms make meaningful changes in treatment or diagnosis protocols. FDA Patient Engagement Advisory Committee (PEAC) Meeting [YouTube Video] After COVID-19 Spurred a Boom in Telehealth, Systems Mull How to Sustain Momentum Event: (10/20) Healthcare Dive recently published an article highlighting the Center for Connected Medicine/Klas Research’s 4th Annual “Top of Mind for Top Health Systems Report”. Among other things the report looked at trends in telehealth reimbursement post-COVID and health system’s potential responses. Description: When the pandemic began both commercial and government insurers waived numerous rules and regulations to increase access to telehealth including waiving co-pays for telehealth visits and equalizing reimbursement for in-office and telehealth visits. While the Federal and State regulators continue to explore which rules to make permanent (for Medicare and Medicaid beneficiaries), some private insurers have recently changed some rules (including the waiver of patient co-pays) for telehealth visits. This survey of 117 executives at 112 provider organizations gave some insight into how provider organizations were planning to respond depending on how these changes settle out. Implications: As noted by Healthcare Dive “a lot of how much [providers] are going to invest in technology is going to have to have to do with what regulations end up looking like.” Since the regulations will to a large extent dictate reimbursement (which were approximately 30% lower for telehealth prior to COVID), despite the recent uptick in volumes, profitability will drive continued usage. For example, over 30% of respondents to the study noted that they were unsure of what they would do if reimbursement returned to prior levels, while 20% said they would continue providing telehealth services and 16% said they would analyze the continued viability of continued use. Moreover, it looks like payment and regulation will be top of mind for the foreseeable future with 25% or respondents noting that payment models and regulation were the top areas for future telehealth improvement. How [Vendor Neutral Archives] VNAs can Address the Challenge of Data Accessibility and Analysis How [Vendor Neutral Archives] VNAs Can Address the Challenge of Data Accessibility and Analysis Event: (10/19) A recent article in Mobihealthnews noted that if healthcare providers had more accessibility to aggregated data, it would be easier to combat difficulties such as reducing clinician burnout, improving efficiency, and increasing patient satisfaction. Vendor Neutral Archives (VNAs) can drive better outcomes by enabling data to be provided as a source of AI, business intelligence, or to deliver clinical information and insights. Description: A recent survey conducted by McKinsey & Company found that data integration and analytics is one of the major trends reshaping imaging services and influencing the future of healthcare. VNAs which allow access to data from any vendor system in multiple formats, improving workflow and reducing the time taken to complete different stages of an imaging exam will enable data to use artificial intelligence to provide decision-making support. This is an essential component in connecting existing systems to open platforms and specialists with patients. VNAs will eliminate the need to switch between systems or wait for data to arrive from other sites because prompt access will be given to correct data from any location in the network. Implications: The world and healthcare in particular is in the middle of a data explosion. The amount of healthcare data collected is currently projected to double every 73 days compared to 2010 when it was said to be doubling every three and a half years. As a result, healthcare costs have been growing faster than expected, and payers are looking to more sophisticated technology to improve the management of costs. Data integration and analytics to realize the value of data have become more crucial for healthcare delivery. Using VNAs will improve clinician workflow, financial, and operational performance of departments and organizations, reduce clinician demand, lower costs, and provide better patient outcomes. How [Vendor Neutral Archives] VNAs can Address the Challenge of Data Accessibility and Analysis CDC's 'Virtual Human' Relays Prostate Cancer Info Through Candid Conversations Event: (10/19) Mobihealth News recently published an article that the CDC launched a prostate cancer information program with a uniquely digital face: a "virtual human" named Nathan who speaks with men about screening and treatment. The CDC noted that the tool can help increase screening since “the decision to be screened and treated for prostate cancer can be overwhelming and complicated” … “some of this is driven by discomfort and long-identified stigma” with a prior examination protocol. Description: "Talk to Someone About Prostate Cancer" takes the form of an in-browser interactive video developed by health simulation company Kognito. In the video, Nathan introduces himself and prompts the viewer by asking how confident they are talking to their provider about prostate cancer screening. Users indicate their response by clicking one of several text responses, prompting a relevant reply, and kicking off a series of question and answer conversation trees. Implications: Prostate cancer is among the most common cancers in American men. Thirteen in 100 men will develop prostate cancer during their lifetime, and two or three will die due to it, according to the CDC. As symptoms vary, there is a high need for men to speak to doctors about whether or not they should undergo screening. Virtual health engagement tools that employ digital avatars can help some patients open up about difficult-to-discuss topics, providing a new way for individuals to become more engaged in their care. The CDC's virtual conversation effort comes after this summer's "Access Initiative for Quitting Tobacco," which combines free nicotine replacement therapies and conversations with a similar digital human named Florence that used a microphone and artificial intelligence to interpret spoken questions. CDC's 'Virtual Human' Relays Prostate Cancer Info Through Candid Conversations COVID-19 Impacts on Cancer Care Event: (10/21) On October 21st, the Journal of Clinical Oncology Clinical Cancer Informatics published an article highlighting the significant drop in cancer screening, diagnosis, and treatment for Medicare beneficiaries. The changes in the utilization of cancer care services is attributed to the decrease in routine healthcare visits brought on by the COVID pandemic.The research was conducted by Avalere, a leading healthcare consulting firm, in collaboration with the Community Oncology Alliance, a non-profit advocating for community oncology practices. Description: The study found that for the period March-July 2010 compared to 2019, there was a significant decrease in cancer screening, biopsies, surgery, office visits, and therapy with variation by cancer type and site service. At the peak of the pandemic in April, screening for breast (-85%), colon (-75%), prostate (-74%) and lung cancer (-56%) were all all significantly lower as indicated. The decrease in diagnosis and delay in care is attributed to the stay at home order to reduce COVID-19 transmission, especially amongst the elderly and immunocompromised. As a result, many healthcare providers accommodated short term adjustments to cancer care delivery, such as temporarily discontinuing non-emergent care screenings, shifting delivery of care to telehealth, and delaying surgeries and other in-office cancer services to reduce transmission risk. Although the stay at home orders were lifted in May and June, utilization of certain oncology services continue to lag, fewer patients are undergoing screening, with many providers and patients choosing to reschedule or completely forego screening, leading to fewer cancer diagnoses. Implications: With the decrease in screenings, diagnosis, and cancer care delivery, researchers found that cancer is likely to present itself at a later stage and require more complex care thus lowering the likelihood that patients will respond and ultimately be cured. To combat this, stakeholders are encouraged to increase awareness of the dangers of medical distancing and regain seniors’ confidence in their ability to safely receive care. Policies and technology to promote access to cancer care have the potential to reduce the projected morbidity and mortality amongst the population. However, further studies need to be conducted to understand the overall impact on different patient populations and potentially take corrective action. COVID-19 Impacts on Cancer Care Researchers Combine AI with EHRs to Improve [COVID] Hospitalization Prediction Event: (10/21) A recent study by researchers at the NYU Grossman School of Medicine has applied AI to EHR (electronic health records) data to predict more accurately good outcomes from COVID-19 treatment. In particular researchers wanted to provide clinicians with actionable information that could be easily integrated into their exister workflows Description: Researchers undertook the study to apply AI to EHR data to help hospitals and doctors more accurately manage patients who had tested positive for COVID. The model analyzed 3000 retrospective cases and developed a model that could identify hospitalized patients likely to have good outcomes with 90% accuracy. In addition, researchers deliberately sought to reduce the number of features and variables used in the model, opting to go with the minimum data requirement needed to make a prediction. Implications: The study predicts outcomes in hospitalized COVID patients with a high degree of accuracy while integrating to current data infrastructure. However, researchers noted the need to remain vigilant when designing AI related tools as there are instances where the physician’s knowledge exceeds that of the machine and must be integrated with the AI output. The researchers also found that to be effective AI learning solutions require two distinct components; 1) addressing a clearly defined use case that clinical leaders will champion and 2) [developing a model that] motivates changes in clinical management, based on model predictions. Researchers Combine AI with EMRs to Improve [COVID] Hosptialization Prediction

What Startups are Missing When They Talk About the ‘Consumer’ Experience & To Boost Inclusivity, Words Matter in the Healthcare World Event: (9/22 & 9/23) Two recent reports in Mobihealthnews focus on the importance of including a health equity agenda and acknowledging the importance of langage to improve consumer experience and inclusivity in digital health tools. Digital health need to make sure they “have delivery systems that communities can trust and want to access” especially for groups of people who have been historically marginalized such as those in LGBTQ+ community and communities of color. Description: Two recent panels shed insights on lessons that could be learned from the dual crises of COVID and racial injustice which have had a disproportionate impact on underserved communities and communities of color. Participants noted that when designing digital solutions for marginalized communities, it is important to take a broad look at health care needs and meet communities where they are. Words and language used by clinicians have impact and can either boost inclusivity or cause exclusion. When designing healthcare solutions, people need to consider – does this work for marginalized communities and what does management and board teams look like from a diversity, equity and inclusiveness standpoint. Implications: Panelists noted that one of the challenges Silicon Valley has in changing health care at scale is that too often entrepreneurs are reflecting their own experiences onto the challenges of healthcare today. One solution would be to tailor efforts towards a specific population served rather than roll out a one-size-fits-all program. In addition, start-ups need to guard against the “Silicon Valley-ization of Healthcare” that focuses on transactions as opposed to relationships and driving outcomes. What startups are missing when they talk about the 'consumer' experience & To boost inclusivity, words matter in the healthcare world Pain and Dementia: Common Challenges for Care Managers [AI in Pain Assessment] Event: (9/21) On September 21st, AI technology pain assessment company, PainChek, released a report entitled “Pain and dementia: common challenges for care managers”, which investigates the complex challenges care managers face daily and the relationship between pain and dementia. In August, PainChek launched its new facial analysis technology in the UK, enabling care workers and clinicians to identify and manage pain in dementia impaired patients who struggle to communicate. Description: PainChek is working to raise awareness of the importance of effective assessment of pain in people with dementia after realizing inappropriate antipsychotic prescriptions were given to dementia patients in the UK. A UK Department of Health study found that of 180,000 patients living with dementia in the UK, 80% of them were inappropriately given antipsychotic prescriptions and at least 50% of people living with dementia in the UK’s 18,000 care and residential homes regularly experience pain. PainChek is using facial analysis technology which enables care workers and clinicians to identify and manage pain in dementia impaired patients who struggle to communicate and assist them with pain management. PainChek has been granted a US patent for pain assessment invention. Implications: Antipsychotic prescriptions are overprescribed to patients living with dementia and the use of AI assistive technology will help promote the move to value-based care, lead to improved patient experiences as well as better health outcomes for patients. One of the biggest challenges is assessing pain levels for people living with dementia. Using applications like PainChek will yield improvements in communication for patients living with dementia, helping improve the quality and appropriateness of care. Pain and dementia: common challenges for care managers [AI in pain assessment] Backed by Google’s Investment Arm, Home-Based Care Startup Ready Lands $54 Million Event: (9/16) On September 16th, Home Healthcare News announced that Ready, an on-demand health care startup has raised $54 million in Series C funding. Ready delivers home-and community-based services, aiming to provide a doctor’s office-type visit in the home. Description: Ready deploys “Ready Responders” — who are trained as EMTs, paramedics and nurses — to hundreds of patients’ homes per day. All responders are connected to Ready’s platform through their phones and are also equipped with iPads, testing and monitoring equipment. When Ready partnered with Ochsner Health System, there was a reduction in non- emergency ED visits by upwards of 70%. In addition, COVID-19 has accelerated Ready’s business in New York. Due to New York’s dire need for health care workers during the crisis, Ready launched a year earlier than anticipated, Ready’s original plan was to launch in New York in 2021, but New York’s dire need for health care workers and providers during the public health emergency sped up the process. Since Ready’s main payer is Medicaid, it was able to extend support to under-served communities throughout the pandemic. Implications: This funding will help Ready continue building out the infrastructure to scale the business, grow visit volume, enhance its product offerings and expand the range of conditions it can support. Even as the pandemic slows down, the company's market continues to grow as patients enjoy the convenience of in-home care. Given Ready's main payer is Medicaid, this service is expanding crucial care in areas of need. Backed by Google’s Investment Arm, Home-Based Care Startup Ready Lands $54 Million Amazon Expands Virtual Medical Clinic Across Washington State: 5 Details & Amazon Care: 5 Things to Know About Amazon's New Virtual Medical Clinic Event: (9/22) CNBC reported that in September 2019 Amazon launched the Amazon Care program, which offers employees virtual medical consultations with clinicians as well as in person nurse follow-ups for company employees and their dependents. Healthcare represents a $3.5 trillion sector for Amazon, which is looking for different avenues to bring technology into the work they already do. Description: The Amazon Care program was implemented to offer employees and their dependents virtual and in person medical consultations with physicians and nurse practitioners. Patients can also use the app to schedule in-home follow up visits, text a nurse on any health topic in minutes, and have medications prescribed delivered to their homes. CNBC noted the application serves to eliminate travel time, wait time, and connect employees and their families to the best trained medical professionals for optimal care. According to Amazon Care Director Kristen Helton, PHD, the program received a patient satisfaction score of 4.7 out of 5, which prompted the company to expand to all eligible employees in Seattle, Washington, where most of their corporate employees are based. Implications: With the rise of COVID, and the need to physically distance increased accessibility to virtual care is even more crucial for the well-being of employees and their families. This underscores the need for accessible and affordable employee healthcare plans which integrate virtual and in-person care like Amazon Care. For big tech companies like Amazon, Google, and Apple, among others, employee health programs represent a way to test new health-care products in an internal research and development lab. Amazon leads the way in making inroads into telemedicine, which represents a $130 billion market opportunity if the company expands its clinic beyond a pilot for its own employees. Although Amazon joined up with J.P. Morgan and Berkshire Hathaway in 2018 to form Haven, an exploration of new ways to manage healthcare expenses for their combined 1.2 million employees, that effort seems to have stalled. This new healthcare initiative may indicate that Amazon intends to pursue certain healthcare solutions on its own. Amazon Expands Virtual Medical Clinic Across Washington State: 5 Details & Amazon Care: 5 Things to Know About Amazon's New Virtual Medical Clinic Microsoft Teams Integrates with EHRs for Provider Telehealth Event: (09/22) A recent article in Healthcare Dive highlighted the fact that Microsoft Teams would integrate with EHRs providers for telehealth and that its industry specific cloud offering for healthcare, Microsoft Cloud for Healthcare, will be generally available at the end of October. Microsoft Cloud for Healthcare includes Microsoft 365, Dynamics, Power Platform and Azure and is aimed at managing patients and staff, deploying resources and promoting data insights. Microsoft also announced the AI-enabled speech-to-text software integration from Nuance. Description: Microsoft noted that its Teams platform, which has a workplace chat, file sharing and web conferencing and is HIPAA-compliant has seen rapid uptake amid the pandemic with telehealth meetings increasing 35% from April to July. Microsoft’s health system clients had pushed the tech giant to integrate with Epic and other EHRs while keeping privacy and security a top priority when creating the video platform for healthcare. In addition, Microsoft’s recent integration with AI-enabled speech-to-text software from Nuance allows patient data entry by automating physician notes taken during a virtual visit which transcribes notes into the correct EHR field, eventually doing so without human supervision Implications: Microsoft’s Cloud for Healthcare and Teams EHR integration allows it to link information and help hospitals with telehealth, care management and patient engagement through apps . This will make it easier for healthcare providers to access data and other services in a remote setting should another pandemic or crisis occur. The integration of Teams and Nuance potentially puts Microsoft at a competitive advantage over other existing large telehealth vendors like MDLive, Amwell and Teladoc, by eliminating the need to integrate a separate distinct telehealth solution and easing workflow via the automatic transcription of clinician notations directly into medical records. Microsoft Teams Integrates with EHRs for Provider Telehealth High-Tech Aids for Aging in Place Event: (9/23) On September 23rd, Kiplinger.com released an update on this year's technology to assist older users and their caregivers who cannot afford the high cost of assisted living/senior care.. Kiplinger’s highlighted six products across a range of devices not all of which are marketed direct-to-consumer. Two we are highlighting here are Smart Sole and Envoy at Home. Description: SmartSole provides a smart insole to fit into shoes with a built-in GPS. This is 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. Envoy at Home is a remote caregiving service for older adults who live alone and can't afford a health aide. Using sensors, caregivers can monitor the person's wellness and safety, such as how long or frequent the patient's bathroom visits are, periods of inactivity, and whether they are taking prescribed exercise or rest. The caregiver can then receive reports and alerts on the patient. Implications: During COVID, many caregivers are socially distancing from their older loved ones and cannot be present to care for them as they are accustomed to or would like. SmartSole and Envoy at Home provide solutions to remotely care for older people living on their own. These solutions and devices like them, help older adults live independently at home longer and provide more flexibility for caregivers by allowing them to care for elderly parents from a safe distance. High-Tech Aids for Aging in Place