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Enhancing Telemedicine Can Close The Infant and Maternal Mortality Gap-The HSB Blog 3/8/21

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

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:

  1. 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.

  2. Invest in patient portals and apps that address the needs of underserved populations.

  3. Track digital health access and usage across sociodemographics.

  4. Focus on patient training in the deployment of new technologies to account for varied digital literacy levels.

  5. Develop workflows that allow clinical teams to engage with diverse patients across digital health platforms.

  6. 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.

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.

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.

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.


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