Direct-to-consumer telehealth aims to give consumers a quick and easy path to healthcare services, but critics say it bypasses a critical element in healthcare delivery: The health system.
As the HLTH conference convenes this week amid the glitz and glamor of Las Vegas, the healthcare industry is facing a conundrum. Direct-to-consumer (DTC) care is blurring the line between provider and vendor and forcing everyone to rethink the concept of healthcare delivery.
And while DTC telehealth might help boost access to care for consumers who can't easily make a doctor's appointment or go to a clinic or hospital, it does have its drawbacks. Some see the platform as way of bypassing the traditional healthcare provider and selling a product—namely, healthcare—directly to the consumer. This, in turn, leads to questions around where the traditional provider fits into the new ecosystem.
As the technology improves and payers begin to support virtual care, hospitals and health systems are debating whether to outsource some services to DTC telehealth providers or launch their own platforms in-house.
HealthLeaders recently sat down for a virtual Q&A with Sachin Agrawal and Miles Romney, president and chief technology officer, respectively, of eVisit, a telemedicine company that partners with providers to offer a branded virtual care service.
Q: How might a direct-to-consumer telehealth program negatively impact healthcare?
Agrawal: Healthcare should have a strong focus on patient safety and quality. When you look outside the health system, you lose years of quality initiatives, patient safety measures, and evidence-based protocols. You also fragment the data. One of our customers reminded me recently that roughly 80% of diagnoses live within the patient's health history. I think technology has changed that statistic a bit, but there’s no doubt that patient history is a primary component of clinical practice. Unfortunately, direct-to-consumer telehealth programs cannot access health history and that all-important and comprehensive patient picture that supports clinical decision-making.
Romney: Direct-to-consumer care offers an episodic approach that tends to keep healthcare fragmented; it works directly against the holistic, integrated approach that physicians have practiced for decades—and which is becoming increasingly relevant, and increasingly possible. Direct-to-consumer programs tend to prioritize cost optimization over patient outcomes. These models have taken some general principles of business scaling and recommended that they somehow guide healthcare delivery. This kind of thinking makes a strong case for 'disrupting the disruption in healthcare.' When people's health and lives are on the line, disruption for disruption's sake is an ethical violation.
Agrawal: Beyond quality and patient safety, direct-to-consumer telehealth programs that partner with health systems to augment their staff are eroding market share. Our health systems need to focus on building an in-house program and shift higher complexity care to virtual where appropriate and substantiate more procedural conversions by closing the referral loop. Provider adoption is often cited as an issue for this model. Still, [healthcare providers can] drive in more revenue and manage provider adoption with the right incentives around virtual care. This is a better strategy than paying a third-party staffing platform with fragmented data and uncontrolled quality.
Q: How should one measure the impact of a DTC platform to show these negative results?
Agrawal: I think we can all agree that virtual care is here to stay and is an expected service for most consumers that will continue to grow in markets served by health systems that have opted to implement it as a distinct service line. One way to look at how outsourcing can negatively impact the health system and care in the long term is the total market share of virtual care. It can be a predictor of patient erosion. Encouraging more specialty care and higher complex care to shift to virtual care throughout the organization can increase access and capacity, capture more market share, and prevent erosion of physical care. It can also help prevent and lower hospital readmissions, ED usage, and waste.
Romney: Beyond comparing quality standards, fragmented data, and lifetime patient value, there’s a fair amount of downstream revenue potential that slips away when a health system partners with a direct-to-consumer program to serve as its digital front door. When that's the top of your funnel, it's like saying, 'I'll save money by outsourcing my sales leads to a competitor.' Organizations can quantify the impact by looking at their average virtual care visit volume outsourced today and the opportunity cost they are giving up by not growing that volume and referring those patients throughout the system. By evolving virtual care workflows to support more comprehensive care, health systems can build a greater volume of higher-complexity visit types and see more patients than they’re able to turn over in the office.
Q: What are the positive attributes of a DTC telehealth platform?
Agrawal: A direct-to-consumer third-party vendor offering staffing augmentation can be beneficial during surges, as long as they are not competitive with the health system and can facilitate comprehensive data exchange between the system and external providers. Still, it should be a backup, and once the health system's capacity returns, staffing services should switch off.
Q: Why are health systems drawn to a DTC telehealth platform?
Romney: Because of the pandemic, many health systems had to implement virtual care strategies quickly and then wait to see what virtual care's future would look like for their organization. Many chose to partner with third-party solutions that offered the technology and the staff because they could quantify cost savings attributed mainly to labor and operational expenses in the short term. Today, virtual care has become a mainstay that can provide access and simplify care delivery, and I’ve already seen a shift in that mindset from the early days of the pandemic.
Q: Do health systems understand the challenges or negative effects of a DTC telehealth service?
Agrawal: Yes, most do, and they are starting to evaluate options as their contracts with the DTC vendors come up for renewal. We are active in those conversations, and they understand the revenue potential that comes from having the right virtual care strategy and partnerships in place.
Q: Do consumers understand this issue?
Romney: Consumers want convenience, access, and a quality of experience equal to their other favorite phone apps. We like to say that healthcare apps have to 'look at home on an iPhone between Facebook and Fortnite.' The DTC companies have been able to focus on that kind of innovation, yes, but at the cost of care quality; while health systems focus on care quality and less on consumer experience in the areas of telehealth and care orchestration. That’s why healthcare organizations need the right virtual care tools—that don't compete with them—while supporting their providers with workflows, facilitating streamlined reimbursements, and meeting their patients where they are.
Q: Can a DTC telehealth platform be designed to overcome these issues?
Romney: Today, there is not a D2C solution that can partner with the health system without competing against them, disrupting their integrated care, and interrupting their revenue funnel, while accurately exchanging patient data, and building the kind of quality and evidence-based care that patients receive from their health system.
Q: How will DTC telehealth evolve?
Romney: The 'how will it' and 'how should it' are blessedly aligned, thanks to the efforts of many in the industry (and certainly not without obstacles) Telehealth will evolve by disappearing. We’re already seeing lines blur between on-site care and remote care. It will all simply become 'hybrid care,' and then simply 'care.' We won’t even think about the difference in modality when some aspects of a treatment course are administered on-site, and some from home—and some continually, invisibly, from wherever we are.
Innovation and Technology Editor Eric Wicklund talks with Sean Whitely, founder and CEO of Axomem.io, about the development of digital twin technology, how it's being used in healthcare now, and how healthcare organizations might use it in the future.
The Global Medical Doctor Validation Association (GMDVA) is looking for technology donations to support care providers working in some of the world's most underserved locations.
While digital health technology and programs have the potential to improve healthcare in the US, their value to healthcare providers in developing countries is even greater.
That's where the Global Medical Doctor Validation Association (GMDVA) comes in. Based in Belgium, the organization provides technology, education, resources, a network, and connections for placement opportunities for providers around the world.
The GMDVA is especially interested in this point at helping providers in underserved and developing countries gain the technology and resources needed to improve healthcare delivery and outcomes, and has launched an effort to collect donated technology.
HealthLeaders recently spoke, virtually, with Vincenzo Costigliola, MD, president of the GMDVA, about his organization and their efforts to expand digital health across the globe.
Q: How, in your opinion, can digital health technology and education make a difference in developing nations?
Costigliola: We are enabling doctors with the 3Cs: confidence, competence, and curiosity. GMDVA works within the framework of the United Nations Sustainable Development Goals (SDGs), especially #3 Education (in this case lifelong health learning), #4 Health and Wellness and #17 Partnerships (by establishing strategic alliances and partnerships in the US, Europe and around the world help create interoperability for universal medicine).
Q. Is this program seeking cash donations only or are you looking for digital health technology as well?
Costigliola: Currently we are seeking donations for a special program to upskill surgeons in developing countries, many of whom themselves are living below the poverty line. This digital surgery program will enable doctors to better engage patients and meet the needs of millions currently waiting for or with no access to surgeries in developing countries.
We are also developing a global ecosystem, so we are always looking for strategic alliances that can help us meet our goal of universal medicine around the world.
Q. Can health systems provide other services, such as digital training or the platform to facilitate digital health education?
Costigliola: Yes, we are always open to working with allies and partners to enhance our Continuing Medical Education and Continuing Professional Development (CME/CPD) programs for learning and development of doctors. Soon we will expand offering these programs to healthcare institutions and all Healthcare Professionals (HCPs). We also work with allies that provide real world application digital skills training to our global doctor community and welcome them to contact us to explore how we might work together.
Q. Aside from this project, what else is GMVDA doing to expand digital health adoption?
Costigliola: GMDVA began with the mission to validate doctors. We are now working to create a global doctor and healthcare professional HCP director on the blockchain. Next, we are developing a system to vet and verify various therapies and treatments, including digital health technologies.
By first ensuring trust in global doctors, then making sure what is being offered is safe, effective, private, and secure, we can then better engage patients, adopt technologies, and innovate digital health together with our strategic alliances.
We are also working on forming a new committee, headed by doctors and scientists from around the world, that will advise on the design and creation of a new decision-making support platform that doctors will be able to access anywhere and anytime to get the right medical knowledge quickly.
Q. Are you working with certain healthcare associations, organizations, or health systems in the US to advance this cause?
Costigliola: We started in Europe, then begin to expand globally. We are co-developing a new Digital Innovation Upskilling Program (DIUP) with our allies that we will be able to roll out to family practitioners/general practitioners (FPs/GPs) throughout the US, then globally to developing countries.
In our model we provide a lot of grants to support doctor digital upskilling in developing countries, and we also are able to subsidize with paid programs in developed countries. We are also currently in talks with the leadership of large cardiology and surgical associations and societies to bring them into our global alliance to co-develop new DIUP programs for their specialty.
Q. Are there any particular technologies or innovations that you'd like to see adopted in developing countries to improve healthcare access/delivery?
Costigliola: We are working with remote digital health and digital surgery solutions providers to help bring these technologies to the developing world. We also plan to digitize all programs to make them accessible to 2,900 medical schools globally to help train younger doctors in digital health technologies and innovation.
We are exponential thinkers: We believe that digital technology will be disruptive, digitized, demonetized, and dematerialized, and then we will be better able to democratize real world experiences and real-world applications of doctors around the world.
The health system has announced a partnership with technology vendor Signify Health, beginning next year, to leverage advanced analytics technology to strengthen the ACO into a population health services organization (PHSO). The strategy is designed to assist the rural network in its shift to risk-based payment arrangements and better manage total cost of care for Iowa Medicare patients.
Leading the charge is Derek Novak, who joined MercyOne's ACO a decade ago and became president of the MercyOne PHSO in February 2019. He says MercyOne selected Signify Health as a partner after realigning its care management model and the organization powering it.
"We took a long look at our overall care management approach," he says. "Rather than just layer on more technology, what we did as an organization is look at it as an opportunity to redesign, really our care management and operation infrastructure."
Technology, nevertheless, plays a role.
"We have a lot of different, disparate data systems across our very broad network of providers," Novak says. "Technology can serve as a vital connection point to those organizations or those systems, being intentional about where it does support those processes for care management and engagement of our members."
Derek Novak, president of MercyOne's population health services organization. Photo courtesy MercyOne.
Numerous factors go into running the PHSO successfully, Novak says.
"While we've been doing accountable care organization work, or value-based work, since 2012, it certainly looks a lot different today than it did then," he says.
"We were very oriented in the beginning of how we perform on our particular contract, on things like improved quality or improved costs. Where we've changed our mindset over the years is, how do we build on that knowledge and that experience of what it took to be successful in those programs, to really transform what does it take to establish competency in performing better no matter what the program is."
For example, the ACO went through various accreditations for its care management plans.
"While we were very oriented on which levers to pull under programs, we now have an accredited program where we apply that methodology across any value-based contract that we bring into our population health services, really standing up an organizational approach to population health," Novak says.
To date, MercyOne has about 300,000 patients in its value-based care program, spanning urban and rural geographics.
As the organization improves its outcomes year over year, he says, both in terms of quality and finances, a shift to operating the ACO as an organization, rather than a program, has allowed the MercyOne PHSO to see more of an upward trajectory.
Another success factor is Novak's background, which doesn't read like a run-of-the-mill healthcare executive bio. Prior to entering the healthcare industry, he worked for industrial manufacturing conglomerate Textron, where he earned a Lean Six Sigma Black Belt certification, useful for keeping tabs on a substantial supply chain.
Five years into his tenure at MercyOne, Novak started bringing those Lean Six Sigma methodologies to bear on the health system, implementing the improvements ushered in by the Affordable Care Act to form its first ACO and move into value-based care.
By 2019, when Novak was named president of the ACO, he headed up the organization's community health and wellbeing initiatives, as well as its business solutions division, determining how MercyOne collaborates and works with employers looking for value-based care arrangements.
A key aspect of the Signify partnership will be extending the same level of ACO support throughout MercyOne's network of rural critical access hospitals and rural health clinics participating in the PHSO program.
MercyOne took time during the pandemic to examine "how do we provide the same level of support to our rural network throughout the MercyOne PHSO that we were also providing to our urban counterparts," Novak says. "Ultimately, that led us to exploring opportunities to bring in a partner like Signify Health."
Novak says MercyOne is fortunate because it has already built out much of the infrastructure that will aggregate population health data from these rural partners--data that will now populate the dashboards that Signify Health will present to clinicians.
The need to realize a short-term return on investment from this new alliance is secondary to the overall PHSO mission.
Officials at the New York health system say future pandemic tracking will benefit from this digital framework.
Mount Sinai has shared details of a new employee contact tracing database developed to control the spread of COVID-19.
Writing in the November issue of The Lancet Digital Health, researchers form the New York-based health system describe the creation of the Mount Sinai Employee Health COVID-19 REDCap Registry, a cloud-based digital framework using a web application known as Research Electronic Data Capture.
The tool is intended to track and reduce the spread of the virus across the Mount Sinai Health System, which includes eight hospitals and more than 400 outpatient clinics.
The database powering the tool assigns unique identification codes for each exposure without intentionally linking each exposure to previous events for that same person or department.
In this way, Mount Sinai can associate events to assist investigations in identifying patterns of the disease's spread. This design also adjusts and responds to changes in the COVID-19 disease as variants such as delta and omicron emerge.
The Employee Health COVID-19 REDCap Registry provides secure, easy to use forms for employee health collection and workflow-monitored contact-tracing information for employees. It also provides qualitative analysis of employee interviews and integrated genomic sequencing.
So far, the initiative has yielded 50,000 employee interviews and more than 500 framework revisions, according to researchers.
The registry is available through mobile and desktop devices connected to the internet, and remote access allows integration at all Mount Sinai Health System clinics and hospitals. The web forms enable swift follow-up from employee health services.
The contact-tracing function captures employee demographics, length of quarantine, which personal protective equipment the employee used, and a recent history of testing for COVID-19. An exposure matrix provides risk scores based on the type of exposure. Supervised machine learning predicts exposure outcomes, according to the researchers.
The registry allowed Mount Sinai employee health services to trim case follow-up times from days to hours.
The Florida-based health system's senior vice president and chief digital and information officer sees digital health innovation as the gateway to precision care.
The influx of direct-to-consumer technology, ranging from wearables to mHealth apps, has had a strong impact on healthcare innovation. But there's a fine line between what might appeal to the consumer and what holds value for the provider.
For Aaron Miri, MBA, FCHIME, FHIMSS, CHCIO, senior vice president and chief digital and information officer at Florida's Baptist Health, the challenge is to sift through all the promising technologies and services to find the diamonds in the rough.
"Anybody can buy something off the shelf, but do you really use it in a way that is conducive to the new normal?" he asks. "Does it help us engage with consumers in ways that they expect?"
Miri is part of a growing trend in healthcare, one that sees health systems approaching innovation with an eye on engaging the consumer—and picking the right person to lead that charge. He joined the Jacksonville-based health system in 2021, after serving as chief technology officer at Dallas-based Children's Health, chief information officer at Walnut Hill Medical Center, VP and CIO at Imprivata, and CIO at the University of Texas, which includes Dell Medical School and UT Health Austin.
He knows what he's looking for in innovation, even if that isn't always easily defined. There are a lot of great ideas, both in technology and strategy, but those ideas often lack focus. An Innovative idea might look terrific, but lack substance.
Aaron Miri, MBA, FCHIME, FHIMSS, CHCIO, senior vice president and chief digital and information officer, Baptist Health. Photo courtesy Baptist Health.
"People too often focus on, for example, the sexiness of the technology," he says. "But that's like saying 'I want to cook dinner.' That's great, but then I'll ask, 'What do you want to cook?' and you'll say, 'I don’t know.'"
For a new tool or strategy to work, Miri says, it has to make clear what the problem is and how it would solve that problem. A good example of that is Baptist Health's deployment this year of two life-sized robots, called Moxi, in pediatric and adult-care settings. The robots run errands and deliver supplies for staff, particularly nurses, while posing for the occasional selfie with patients.
Miri says the health system was faced with a staffing crisis, with more than 1,000 open positions, and nurses and other care providers were stressed out. Moxi is designed to help alleviate some of that stress by taking on the chores that take up so much of a nurse's time but don't really allow them to be nurses.
Another innovative project saw Baptist Health partner with Gozio Health to develop a wayfinding platform, giving visitors clear directions to and around all of the health system's properties, enabling patients to find their way quickly and easily to appointments. Miri says Baptist Health saw some 15,000 downloads of the mHealth app during the first month, and they're now integrating that platform with their Epic electronic health record platform and eyeing other services.
Yet another program saw Baptist Health partner with Blue Zones to identify community-based social determinants of health and create programs that address community health and wellness, including food banks and affordable housing.
"This is where we're going as a health system," Miri says. "We are a thought leader on this."
One of the keys to this strategy, he says, is data.
"The industry right now is reacting to the fact that there's a sea of data out there," he says, noting the presence of more than 2 billion PACS images alone. "There are a lot of things that you can do with that data that we haven't even thought of yet."
For that reason, Miri sees data analytics and AI as a fast-growing priority in healthcare. Health systems must not only know how to collect and use that data, but how to use technology to make collection and analysis easier, while avoiding burdening clinicians. Alongside that, they'll need to pay attention to data transparency, so that everyone knows where that data resides and who owns it, allowing for a seamless exchange between who has it and who needs it.
Beyond that, Miri says healthcare will also pay more attention to the power of automation, and how robotics and robots can make a positive impact. Moxi is just one example of a segment of the industry that is growing quickly.
"Healthcare is incredibly complex, and we're getting smarter in how we do things," he says.
That's why he's careful in how he looks at start-ups and innovative new companies in the healthcare space. Anybody can come up with a great solution that promises to make healthcare better, but the companies to keep an eye on are the ones, he says, that "understand healthcare." They know how to do the dirty work that needs to be done in order to make those solutions work. That's not always the case with companies that "think outside the box."
"Identity is the cornerstone to digital transformation," he says, citing the potential to tailor treatments and other resources to the individual. "And it's mind-boggling how identity is being left on the sidelines."
Miri would like to see digital health technology brought to bear on creating what he calls "the golden record," a complete and accurate healthcare record that leverages blockchain technology, follows the patient, and is bidirectional, matching patients to resources and resources to patients. This would also go a long way towards eliminating data silos and incomplete or inaccurate patient records that hamper clinical care.
And that's in the future, where Miri is focused. He doesn't believe in looking back and says the competitive nature of today's healthcare landscape is good for the industry, as it forces innovators to be relevant.
"If you're going to be sick, you’re going to go to the best place possible," he says. "And that's us."
Researchers at Penn Medicine report that a simple, automated messaging platform that connects with patients after they've been treated in the ER greatly reduces the chance of rehospitalization or further emergency care. It's also great for staying in touch.
New research has found that even a simple 'How are you?' e-mail or text from a care team can improve clinical outcomes post-discharge.
This comes from the University of Pennsylvania's Perelman School of Medicine, whose researchers analyzed the effects of an automated messaging platform from primary care providers to patients who'd recently received emergency care at a hospital. The study, published in the Journal of the American Medical Association's (JAMA) online site, points to the value of a simple messaging platform in improving patient engagement, reducing rehospitalizations and boosting overall outcomes and wellness.
“Contact from a primary care practice can help patients feel more connected and enable them to access care in a timely manner,” Anna U. Morgan, MD, an assistant professor of internal medicine at Penn Medicine and the study's senior author, said in a press release.
“In a fragmented healthcare landscape, relatively simple applications of technology can help patients feel more connected to their primary care practice,” added Eric Bressman, MD, a fellow in the National Clinical Scholars Program at Penn Medicine and the study's first author. “This is especially important as patients recover from acute illness, as it reminds them that they have a medical home to which they can turn for support.”
In the study, researchers compared outcomes for more than 400 patients who opted into the digital health program against more than 1,000 who did not participate. Patients were contacted by phone two days after discharge for an emergency care visit and asked if they'd like to enroll in the text messaging program. Those who did were sent check-in messages at regular intervals over a month, with the texts tapering off as the month progressed.
According to the research, patients in the text messaging program were 41% less likely to need any kind of acute care after discharge; more specifically, they were 33& less likely to return to the emergency department and 55% less likely to be rehospitalized.
"The program’s high degree of automation required minimal effort beyond usual care," the study pointed out. "To the best of our knowledge, this is the first study to experimentally test the benefit of an automated texting program on post-discharge outcomes among primary care patients. The mechanism through which this compound program prevents use of acute care is likely complex, but we theorize that more frequent check-ins and a lower friction medium for patient-initiated outreach lead to earlier identification of needs and a greater likelihood that issues will be escalated to and handled by the primary care practice than another setting."
Bressman and his colleagues also noted that almost 83% of the patient enrolled in the program responded to at least one of the introductory messages, a much better response rate than to the traditional phone calls. And less than 9% opted out of the program.
The study points to the value of simple, even automated, contact, giving patients the reassurance that their care providers are looking after them after a healthcare emergency. This, in turn, prompts patients to be more mindful of their care plan and their health, and to respond quickly if they have any concerns or symptoms.
The annual survey by the College of Healthcare Information Management Executives recognizes healthcare organizations that have successfully adopted digital health technology.
The organization's survey, covering more than 38,000 healthcare facilities in 10 countries, targets healthcare systems that "exhibit an outstanding record of leveraging the power of digital technology within a visionary corporate strategy." The list is divided into acute, ambulatory, and long-term and post-acute care (LTPAC) organizations.
It also points to the growing interest in adopting digital health tools and strategies in the wake of the pandemic, during which healthcare organizations looked to expand their connected care options and develop more programs to reach consumers. CHIME executives noted that this year's survey has grown by 20%.
“Deeper analysis of the data shows the major efforts underway to transform the way we deliver care as facilities up their digital game in areas such as patient engagement, clinical quality, security, and data analytics,” Russ Branzell, CHIME's president and CEO, said in a press release.
The health systems awarded Level 10 status in the acute care category are:
Jefferson Health- Abington
Cedars-Sinai
Geisinger Health
Jackson Health
Jefferson New Jersey
Jefferson Health - North East
Lehigh Valley Health
Mayo Clinic
NYU Langone Health
Parkview Health
Spectrum Health
Thomas Jefferson University Hospital
UC Davis Health
UCHealth
UPMC
University Health (Texas)
University of Utah Health
West Virginia University Health
This year's survey included an unscored section on digital transformation to, as CHIME put it, "allow for data gathering on responses to emerging digital health trends without impact to an organization’s rating."
“We are excited to recognize those in the forefront of digital excellence,” H. Stephen Lieber, chief analytics officer at CHIME and a former president of the Healthcare Information and Management Systems Society (HIMSS), said in the press release. “Their pioneering performance inspires other organizations by example. Patients in communities around the world receive better care because these providers drive change through digital transformation, as they have proven through their success in this rigorous survey.”
Healthcare organizations are using digital health technology to help doctors and nurses communicate with patients who speak different languages, aren't comfortable using English, or have other communication challenges.
With more than 800 languages spoken in the New York City area, communication challenges are a very real possibility. And nowhere is that more dangerous than in a healthcare facility, where an incorrect translation could affect clinical outcomes.
Healthcare organizations are turning to technology to address that challenge, with partnerships and digital health platforms that enable care teams to access interpreters in real time.
"We deal with a melting pot as far as diversity goes," says Kerry Donohue, MSN, RN, manager of patient experience and culture leader at Manhattan Eye, Ear, and Throat Hospital (MEETH), a division of Northwell Health's Lenox Hill Hospital. "Every day, I'd say one out of every five patients [speaks a language other than English}, and it can be challenging."
When confronted with a patient speaking Farsi, Romansh, Mandarin, or any other language, the traditional tactic would be to look for a multilingual family member or grab the nearest staff member who just happened to speak that language—at least that's what happened in St. Elsewhere—or grab a phone, call the hospital's translation service and hope they had someone nearby who knew that language.
Digital health technology has made that process easier. Care teams can now use a smartphone or tablet to connect through an mHealth app with an interpreter in real time, even by video, on a platform that specializes in translation services. MEETH, for instance, uses LanguageLine services on tablets provided by Equiva Health, a digital health patient engagement company based in New York.
"It's like FaceTime," says Donohue. "You're connected with someone who knows the language."
Making sure patient and provider are speaking the same language is critical in healthcare, and it goes far beyond patient engagement. Doctors and nurses not only need to know exactly what happened and how a patient is feeling, but that their questions, diagnoses and care plans are understood. Something lost in translation could result in a missed symptom that indicates a more serious health issue, or a misunderstood prescription or treatment plan that could make things worse, even fatal.
"It's really not best practice to use a fellow clinician or a family member as a translator," Donohue says, noting that a trained medical interpreter can pick up nuances in both language and clinical terms that others might miss. In addition, this resource means providers don't have to pull in colleagues to help with translation, interrupting other workflows and affecting patient care.
The language barrier isn't just in New York City, either. From Maine to Hawaii, in communities and healthcare sites large and small, the chance of coming across someone who speaks a different language—and who may not speak English at all—has grown. And with the advent of telehealth, more hospitals are engaging in virtual care with patients and other providers in different parts of the world.
In Boston, Brigham and Women's Hospital is testing a device-agnostic website and app called CardMedic, designed to tackle both language and communication barriers, including visual, hearing and cognitive impairment.
"You need as many tools as you can get to help communicate with patients," says Andrew Marshall, MD, an emergency medicine physician. "Clinical questions don’t always fit well into a box, and interpreters aren't always available."
Marshall sees the technology addressing a key social determinant of health that affects care for a wide array of underserved populations. If someone is uncomfortable talking to a care provider in another language or has issues communicating, he or she might delay going to a clinic or hospital or even skip the visit altogether. Or that person might come out of a visit to the hospital or doctor's office with questions about what was said or communicated.
"Brigham and Women's has a robust interpreter service, but you need to make sure" that every word is understood correctly, he says. That might mean using sign language, or providing visual cues or a vocabulary for someone with cognitive issues.
"God forbid you end up having to use Google Translate" to explain the intricacies of diabetes or a heart condition, he adds.
Equiva and CardMedic are part of a wave of innovative ideas aimed at tackling communication barriers in healthcare. Aside from apps and websites that can handle interpretation, there's ongoing research into natural language processing (NLP) and voice activated technology—imagine Alexa handling these tasks in an ER or doctor's office. Other ideas include robots, avatars, and wearables, even smartglasses and hearing aids, that can handle translation.
"At the end of the day you're making physicians into better physicians," says Marshall.
The Memorial Healthcare System is focusing on food, housing, and transportation to help reduce unnecessary ED visits and boost care quality.
A Florida health system is putting social determinants of health (SDOH) right into the electronic health record problem list, where doctors can see and act on them.
Spearheading this initiative is Jennifer Goldman, DO, chief of Memorial Primary Care at the six-hospital Memorial Healthcare System, based in Hollywood, Florida. In this interview with HealthLeaders, Goldman explains how SDOH is embedded in the EHR and used to improve outcomes. This interview has been lightly edited for brevity and clarity.
HealthLeaders: How important is the role of data these days in the practice of medicine?
Jennifer Goldman: It's inseparable for primary care as we've transitioned from a fee-for-service to a value-based care approach. It's imperative that our teams know what's going on with those patients.
[In the past], it wasn't that we didn't care, but we didn't have the data, and we also didn't have the payment structure to make it possible. Now with value-based care, we have both. The care teams utilize that information to reach out to patients who haven't had an appointment and ensure that they come in. It's that kind of proactive management that is inseparable from data and data analytics.
Jennifer Goldman, DO, chief of Memorial Primary Care, Memorial Health System. Photo courtesy Memorial Health System.
As a result of having that data, we started something called a shadow schedule, where instead of booking directly on a provider's schedule and needing to have an open slot for a walk-in, we would have an empty schedule every single day that we just set out for walk-ins, for same day appointments, whether that was telehealth or face to face.
We've noticed a sharp increase not only in the number of patients that were requesting appointments via that system, but we also saw over 830 walk-in patients, same-day patients, in the last month alone. And we noticed a commensurate decrease in the number of ED visits. We would only be able to have that insight and that information because of the data that we proactively looked for.
HL: A JAMIA report from 2021 found there is no consensus on which SDOH measures should be captured in the EHR. How do you decide which ones to add?
Goldman: That's an ongoing discussion in our system. We utilize Epic, which has a social determinants of health wheel, which is just a graphic representation of the varieties of determinants of health that somebody is dealing with. And the major challenge for us in our organization was to determine which ones we were going to prioritize and start with.
We don't know if all of them truly impact health equally, but we do know that there are three that are a priority not only for us, but for Medicaid. If we can do something about these, we can probably impact more in a person's health than if we address resources elsewhere. Those are food, housing, and transportation. Substance abuse is a huge social determinant of health, but we already have a process for that, where we already screen everybody for that when they come in. The three social determinants of health we focus on are traditionally outside the wheelhouse of any physician. Those are things that we just did not ask people.
HL: How do you capture the data about the need, and how do you match the need with the actual service?
Goldman: We utilize the Epic release social determinants of health wheel. And we ask first our health coaches, our nurse navigators, and in some cases our social workers to review these determinants for the patients that were on their high-risk panel, patients that have significant ER visits or who are ill with multiple different chronic conditions.
We focused first on that population. Case managers were asking some of those questions anyway, but they were asking them in a non-capturable, non-standardized way. We standardized the way that we were capturing that data so that we could run analytics on it and show that information in the EHR to physicians. If our providers don't know that the patient they're treating right now is homeless or doesn't have access to healthy food or doesn't have access to transportation, that would probably impact their decision-making in terms of what treatment they were going to prescribe for that person.
We built something called an alert or a best practice advisory, where if somebody screened positive for homelessness, food insecurity, or transportation need, that would pop up [in front of] the clinician. And we took that a step further, because sometimes pop-ups in the EHR are negatively looked at. I never wanted to have an empty best practice advisory, where the doctor would have to do five more clicks to document that in the EHR. We drop the code for that specific social determinant of health into the problem list and into what we call a visit diagnosis.
We also included documentation that the patient was going to be automatically sent to our care team for follow-up in terms of how to access resources. We did that by having an automated in-basket so that it didn't hinge on a physician or a nurse practitioner or PA remembering to involve a social worker. This would happen automatically. We work with our community resources, such as the Broward County Task Force on Homelessness, and many other housing resources, as well as transportation assistance. With food, we work with multiple local food banks. We do direct connections with people we call and get those resources for them, instead of just handing a piece of paper to a patient.
HL: When did these processes go live, and what are the outcomes like so far?
Goldman: These alerts went live six months ago, and the outcomes have been significant. We've tripled the number of ICD-10 codes in the EHR for social determinants of health. That means that our physicians are documenting three times more on homelessness and food insecurity and transportation than they were previously. So we know that it's being captured.
We know that interventions are being done because we can track that as well. And we know that all those social determinants of health that we're screening for, all those patients ended up getting a referral to the care team and the care team contacted them and gave them the resources that they need. We're in the process of measuring outcomes, which ultimately is the most important thing. We're looking at data for no-show rates for appointments.
HL: What are the success factors for you in your job as a leader in this effort?
Goldman: Number one is making a difference in the community that we treat. Having the data to show that we are making a difference in our community is a success factor that's huge. More granular than that is ensuring that all our physicians are on board with this, number one, and number two, understand the why behind asking all of these soft issues in a medical visit, and make it easy for everybody to screen and document patients for social determinants of health without our doctors feeling like they have extra work to do.
Third would be our performance in our value-based care contracts. How successful are we in our quality measures, which we have done successfully every year, also ensuring that our patients are not utilizing services that they don't need, making sure that we're available so that people don't need to seek care in the emergency room for something that's not an emergency, and also ensuring that we're making sure that people don't need to go unnecessarily to specialists for care if the primary care doctor can address those issues.
HL: What about the other social determinants of health -- child care, money for medication, and so on?
Goldman: We absolutely want to expand into that. There are ways to do that over time. For every appointment, our medical assistants are now going to be screening for the social determinants of health. We're also moving into a way that our patients can answer these questions in the lobby, as they're waiting for their appointment, or at home as they're waiting for their telehealth appointment. And I want to be careful not to put forth technology to replace human beings in these questions that we're asking when not everybody has access to that technology just yet.
