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Telehealth Could Magnify Inequity For Those Who Lack Access-The HSB Blog 2/16/21

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 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.

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.

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.

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.

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.


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