Digital Technology Will Shift Care from Hospital to Home-The HSB Blog 3/1/21
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.
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.
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.