Researchers at the University of Michigan, analyzing Medicare data through 2021, are reporting that the traditional Medicare population used telehealth during the pandemic to access care, but they haven't been overusing the platform.
A popular criticism of telehealth is that people will be using it more than they should, leading to unnecessary healthcare appointments and expenses. But researchers at the University of Michigan say that's not true in the Medicare market.
An analysis of Medicare data through 2021 finds that while virtual visits have increased considerably as a result of the pandemic, with roughly one-third of traditional Medicare members taking part in at least one telehealth visit last year, those numbers aren't excessive. This means that the Medicare population, comprised primarily of older Americans, is using the platform to replace in-person care, rather than just because they can.
“As telehealth use hits its stride in the Medicare fee-for-service population, the fears that flexible telehealth rules might lead to an increase in the total volume of outpatient visits has not panned out,” Chad Ellimoottil, MD, MS, director of the Telehealth Research Incubator at UM's Institute for Healthcare Policy and Innovation and lead author of the study, said in a press release. “With all the evidence we have to date, it appears that telehealth has been used as a substitute for in-person care rather than an expansion of care.”
The distinction is important, especially as the nation moves away from the pandemic and the healthcare industry looks to adopt a long-term telehealth strategy when the public health emergency ends. Advocates say telehealth should be a standard practice of care, comparable to in-person care and regulated along the same lines. Opponents argue the platforms is ripe for misuse and abuse, and that it should be governed more strictly to prevent waste and abuse.
Ellimootil and his colleagues found that about 9% of all outpatient appointments made by people with traditional Medicare coverage were virtual in the latter half od 2021. That represents a decline in virtual visits compared to the time period between mid-2020 and mid-2021, but a large increase compared to prior to the pandemic in 2019.
The surge in telehealth use during the pandemic was helped by a series of federal and state waivers aimed at increasing access to and coverage of telehealth, so that health systems could protect their staff and isolate those infected by the COVID-19 virus from others. Those waivers will end with the end of the PHE, and telehealth supporters want new or revised regulations in place to continue the momentum and allow health systems to continue their programs.
The Center for the Undiagnosed Patient at Cedars-Sinai takes on healthcare's most perplexing cases, and has helped several patients get their lives back.
Healthcare is complex, and not without its mysteries. Sometimes healthcare providers have to be detectives to figure out a diagnosis and treatment.
At Cedars-Sinai, a team of clinicians from a wide range of specialties gathers every week to tackle one particular mystery. They're part of the Center for the Undiagnosed Patient, a specialty clinic launched in 2017 to help patients whose conditions defy identification.
HeralthLeaders recently sat down (virtually) with Leon Fine, MD, a professor of medicine and biomedical sciences at Cedars-Sinai and medical director of the center, to talk about the center's mission. This interview has been edited for length and clarity.
Q. How was the Center for the Undiagnosed Patient launched?
Leon Fine: There was a sense that existing medical diagnostic systems, even in academic medicine, were failing to address a segment of the patient population that was left undiagnosed, frustrated [and] uncertain. There was a substantial level of underlying anxiety [with patients] about their condition due to its chronicity and the inability of the medical community to solve the problem.
So we set up something, and were careful about naming it. We called it the Center for the Undiagnosed Patient, singular, rather than Center for Undiagnosed Patients, plural. There was something quite specific in deciding that, in the sense that each prospective patient would have to have a good sense that we were really interested in them personally, and that we were about to address their problem.
Dr. Leon Fine, medical director of the Center for the Undiagnosed Patient at Cedars-Sinai. Photo courtesy Cedars-Sinai.
Who are these patients? Many have what would be broadly called rare diseases, very infrequent diseases that most doctors haven't encountered. Another group of patients has more traditional diseases: heart failure, lupus, atherosclerotic heart disease, etc., but present in atypical ways. There are also patients with multiple diseases involving multiple organs, called comorbidities. They may have had a presenting symptom that is a single thing, such as chest pain or shortness of breath, but behind that there is a series of diseases which actually could have contributed and have to be taken into consideration.
These are all long-term patients. Many have seen multiple specialists; it's not unusual for patients to have seen more than a dozen doctors, sometimes many more, each one bringing to the table their specific area of knowledge [but not] seeing the whole patient.
The question was, if we were to set up a new entity called the Center for the Undiagnosed Patient, why would any patient want to come and see us? Because we would just be the 12th doctor. Why would they have any more confidence in coming to see us, because they'd already seen so many doctors. That to me was a very central question to be answered.
The answer came with a notion that the only way we could do it was to bring a so-called team approach to the patient. Number one, the patient would access our center, and it was absolutely essential in this age of online medicine that the patient be seen personally. Number two, the leadership team at the center was constituted of generalists and not specialists.
Every patient who was presented would first be considered by a team of at least a half a dozen doctors [who ask] 'Can we possibly help this patient and could the weight of opinion of six talented and capable people have more impact on the patient's belief than just seeing yet another doctor?'
Q.How are the patients screened?
Fine: A patient can access the center online or by picking up the phone and talking to someone. We require that the patient's background information be made available to us. Nowadays that's much easier, because a lot of this information is in the electronic medical record, but in many cases it's not. And in many, many cases, the narrative of what happened to the patient and the timeline was missing. You get soundbites, as it were, of information, and getting the story becomes that much more difficult.
We require a referral from a doctor, because it's much more convincing if the doctor is the person who's providing the information, but we do open the door to patients accessing us directly. The reason is we are not a treating center. We are a diagnostic center. So if we are able to come up with some useful answers, we want to feed them back to someone who can then take that patient by the hand and lead the patient through a whole series of therapeutic options and therapeutic trials.
We have a very talented nurse practitioner (Jennifer Elad, DNP, ACNP) who spends hours, literally, going through the patient's records. There are often hundreds of pages of records that have to be screened. We've even had a patient with a thousand pages of records. It requires many hours to sift through these records, and it's even more difficult to put them into some sort of context, like a three- or four-page summary, which can then be presented to our leadership team.
Along with that summary, [Elad] has also spoken to the patient. A presentation is then made to the group, which consists now of three lead internists, a lead pediatrician, myself, and the associate director, another generalist who has a specialty in pulmonary medicine.
The first question to be asked is, do we think we can be helpful by taking on this patient? If the sense is not really, we don't waste the time of the patient or our own time in pretending or hoping that we can do something. There's a small number of applicants who we tell, "We are terribly sorry, but we do not think we can be help with you."
I should point out that in order to cover the cost of the hour spent going through the record, we do require that the patient pays $500. That hardly covers, but certainly contributes to the patient's commitment to us as it were.
If we decide that this is a patient that we want to take on, we then [ask] how are we going to approach this case? Which of our lead internists will take the case?. We also have approximately 25 specialist consultants. And we have a psychiatrist on our team. [Similar] centers that have sprung up around the country have chosen to deflect the psychiatric case from their interest, because they don't feel that this is part of what they're all about. We have recognized that there's no patient we have seen that doesn't have a psychological overlay to the problem. We can then refer the patient to a psychiatrist if we feel that was a dominant component of the problem.
We assign the case to one of our lead internists or pediatrician, who then sees the patient face-to-face. With COVID, we had a number of patients that we couldn't do the face-to-face, but we were not prepared to compromise on that. We must see the patient, because medicine is about taking a very comprehensive history. Looking at a patient and talking to a patient gives you an immense amount of information that you simply could not get online.
We try not to duplicate some of the specialists the patient has already seen. If someone has an issue relating to rheumatology, they've already seen three rheumatologists, each with a different twist. We're very careful about that, because this is not going to really enhance anything.
Once the patient has been seen by a selected group of specialists, it goes back to the original generalist to summarize the case, which then is represented to the group, and that closes the loop.
We've been going now for a few years. The number of cases we see, because of the time commitment, is not large enough to do any statistical analysis. But off the top of my head, I can roughly say that we make a new diagnosis with a name in about a third of our cases.
Another third of patients gain substantially from the encounter because we're able to confidently tell them that they don't have all the awful diseases they thought they had. You do not have cancer. You do not have a heart that is failing. You do not have blood vessels that are not working. Most patients believe us, but of course some still don't believe us, and we know when they leave us, they'll go to the 13th doctor. Nothing we can do there.
The other third of patients, we simply don't know. We've gone the whole route, and we honestly say, 'We simply cannot solve your problem.' We do say to them, 'We'd be very happy to see you again, let's say in six months' time, to see if something has evolved, and we'll be able to see whether we can add anything.'
Q. How long does it take for you to come to a conclusion on a patient, whether it's a diagnosis or you can't diagnose?
Fine: In most cases, we make an opening for this person within two weeks. The initial evaluation takes maybe a week or two. It takes us another week or two to get an appointment for the person to see the generalists, and we try and make sure that the consultants are available around that time.
I'd say that it probably takes a couple of months, but there are some patients who take much longer. Patients who come from afar, from out of state. It does not happen in our center the way it does in some institutions where the patient comes in, and two days later they get a printout. We cannot do it that way, and we don't pretend to do it that way. We are being very thorough.
Q. What about the patients that you can't do anything for? What's the next step for a patient like that?
Fine: That's one of the most frustrating and disappointing parts of diagnostic medicine. We can see they are flailing around looking for a doctor who can help them, so the referring physician is a very important element in the whole cycle.
If the patient says, 'Well, can you make a suggestion?,' we try not to make suggestions about doctors in our own institution, because that could be self-serving. Our function is to help with the diagnosis We can confidently say that we don't think the patient has this, that, or the other. It's just possible that something will emerge later, where we can be of help.
Q. You mentioned about a third of the patients you are able to find a diagnosis for. How does it feel to be able to help someone who's been looking for help for so long?
Fine: That's the reason we do it. There was a woman in her 70s who suddenly started getting frequent episodes of abdominal pain. Every time it occurred it was slightly different, in a different point in the abdomen, for a different [length] of time, and it started getting worse and worse. She goes on pain killers. Some work sometimes, some don't. This went on for a number of years.
We took the history, and we presented to the group all the CT scans that had been done with the abdomen that were negative. There was nothing there that we could see. Then one of our group said, 'Has the patient ever had a CT scan of the abdomen during an episode of pain?' We looked through the record, and the answer was no. And he told the patient, 'When you next have an episode, we would like to see you and do a CT scan on you while that happens.' The patient had an episode that lasted a day or two, came to see us, we did the CT scan on the abdomen, and guess what? We found that she had a partial bowel obstruction in the abdomen.
Our surgeon went in, found that the piece of bowel was adherent to this little opening, freed it under laparoscopy, and closed the little opening through which the bowel was protruding. The patient has never had pain since then.
That was remarkable. And all that we did was to ask a single question. Had we not done that we wouldn't have seen the distension of the bowel due to obstruction, we couldn't have made the diagnosis. That was just an interesting case. I'm not suggesting that all of our cases are like that, but that it certainly illustrates how a single insight can be a key insight in some cases.
Q Are diagnoses confusing or complex, or are they unusual?
Fine: They tend to not be unusual. They tend to be diseases which present in a complex way and which we simplify because of our breadth of expertise. We say, 'Let's not focus on that particular symptom that would seem to be peripheral.' If you see a problem list for patients, there are at least a dozen things on that problem list, and each one has value. We try to prioritize what we think the most important or the second most important is.
These are [usually] relatively common diseases. But there are also a number of new ones. Every time you open the New England Journal of Medicine, there's a new genetic disease that has been described. So we do genotyping on our patients. We analyze the genome when we think there may be a genetic explanation. We get the report, and anything that looks like it may be a mutation or an unusual polymorphism of the gene, we look in. Data analysts look at the record to see whether there are any other cases which are linked to that particular abnormality.
We have had cases where we discovered something which didn't make any sense, and we went out into the international community and said, 'Has anybody else seen a patient like this' Sure enough, some have, and eventually there is a whole network of doctors who've seen one case.
You could say, if there's nothing you could do for the patient, what good is it for the patient? The answer is, patients do feel comforted that a name can be applied to their condition, that other people have it, and maybe someone now will start looking for a solution to the problem. That's where publishing in an academic setting comes in. The group publishes together, the disease gets a name and an understanding, and that often opens the door to someone saying let's try this. It works for them.
Q: the resources you have at your disposal, you pretty much can go anywhere for help on these types of cases.
Fine: We do have a broad range of consultants. Cedars-Sinai is one the leading academic medical centers in the country. We're proud of that. And I must say that the reputational value of the Center for the Undiagnosed Patient is appreciated by its leadership.
Think about this: The practice of medicine today is very much dependent on income generation. What doctor can spend a few hours with a patient and legitimately bill that patient for the time they spent? Are we generating large amounts of money for the institution? Absolutely not. Is the institution proud of this entity and does it believe that it is something that enhances their reputation in a very positive way? Absolutely yes.
There are two dimensions to this. One is the training of younger doctors, which we haven't yet done but we want to do. We would like to bring in medical residents in training, to listen in and participate and see how we analyze things.
We are also now starting to build a strong research arm at the center. We're very lucky to have some very talented people who study the biochemical components of diseases. So we will get a patient in and we will take some blood samples and urine samples and various things, send them to these biochemists, and they analyze the genome, they analyze the patient's lipids, they analyze the patient's metabolic products. They see a pattern for the patient which can be looked at side by side with the patient's physical and clinical presentation.
Now, you can't make much of one or two cases, but when you have 20 or 30 cases of someone presenting, let's say, with an irritable bladder, you might see patterns of expression of various genes and various proteins that are different amongst that group of patients. Some present this way, some present that way. And then you say, maybe our description of this as cystitis is oversimplistic. These patients seem to have three different diseases, all presenting in the same way, but if that's the case biochemically, then clearly the diagnostic and treatment should go along with that.
Q: What does it feel like to finally solve a riddle, to be able to give a patient the answer to a question that may have evaded everybody else, and they finally got an answer that they've been so long waiting for?
Fine: We do have a sense of triumph. My God, look at it, something so simple, and we solved it. We are known as a group that tries to tackle medical mysteries. I don't think that sense of triumph happens as often as you think it might. Sometimes the contribution is only partial, not complete. And I can remember where we actually made the specific diagnosis and it was clear that it was a rare diagnosis and we were very happy that we made it, but the patient's symptoms didn't get better as a result. We said, 'Who knows, maybe we haven't solved it yet.' So we're very cautious and I hope modest about not overplaying what we've achieved.
The Connecticut-based health system is partnering with Wellinks on a program that will equip patients transitioning from the hospital back home with digital health tools, an mHealth app and virtual connections to their care team for rehabilitation and coaching.
Hartford HealthCare is launching a new program that will use digital health tools and virtual care to help patients living with chronic obstructive pulmonary disease who are transitioning from the hospital back to their homes.
The Connecticut-based, seven-hospital, 400-site health system is partnering with digital health company Wellinks on the program, which will give qualifying patients access to care management services at home for as much as 16 weeks. And it targets a population that has frequent interactions with care providers.
“Although COPD is the third leading cause of death by disease in the United States, estimated to cost $49 billion in care annually, innovation in COPD care has trailed other disease states," Syed Hadi, MD, a hospitalist at Hartford Healthcare, said in a press release. "Acute exacerbations of COPD often result in hospitalization, and a quarter of patients will be readmitted to the hospital within 30 days.”
The health system is one of many across the country using telehealth and digital health to expand and improve chronic care management for patients with a variety of health concerns, including diabetes, COPD, chronic heart disease, asthma, Parkinson's and Alzheimer's. Program range from simple, daily check-ins with a care team to report vital signs and symptoms, to more elaborate remote patient monitoring services that might include continuous monitoring and even in-person care.
The program aims to improve care management and reduce unnecessary hospitalizations by giving patients an mHealth app and connected devices when they leave the hospital, to allow them and their care team to monitor vital signs, track health data and stay in touch at home. Those patients will also have access to virtual rehabilitation and personalized health coaching.
“COPD is a complex medical condition that requires a multidisciplinary team approach," Abi Sundaramoorthy, MD, MBA, Wellinks' chief medical officer, said in the release. "When patients are recovering from hospitalization, care gaps are difficult to close and can have a negative impact on outcomes."
The program, which will track hospital readmissions as well as clinical outcomes and compare that data to a control group of patients receiving traditional, in-person COPD care management, was facilitated through Hartford HealthCare Innovation, the health system's innovation arm.
The health system has worked with more than 20 digital health start-ups, including New Haven-based Wellinks, through its Center for Education, Simulation & Innovation. It is also partnering with the Israel Export Institute to bring Israeli-backed and -developed technology to the US, and has joined at least two accelerators aimed at improving the pipeline for new technology in healthcare.
“Our innovations really focus on four platforms,” Hartford HealthCare CEO Jeff Flaks said in a separate press release. “It’s about access, affordability, quality, and health equity. All of the innovation work we do goes across those four domains.”
A new survey finds that both patients and providers see value in telehealth visits as a complement to in-person care but not a replacement. And they don't like distractions.
A survey of patient and provider attitudes toward telehealth find that both see the virtual visit as a complementary to the in-person visit, but not as a replacement. And they both certainly know when a virtual visit isn't working.
Compiled by the New York-based telehealth scheduling company Zocdoc, the survey, taken separately of patients and care providers between May 2020 and May 2022 and combined with an analysis of appointment bookings, charts the increase in telehealth visits during the pandemic and a decrease in recent months as the COVID-19 crisis has waned. It found that roughly one-third of all visits were virtual in 2020, as the pandemic peaked, and that number dropped to 17% as of May 2022.
The one exception is in mental health services. Some 74% of mental health appointments were for virtual services in May 2020, and that number rose to 85% in May 2021 and has increased to 87% in May 2020. The numbers show that both patients and providers are finding a comfort zone in telehealth for mental and behavioral health services.
Perhaps more intriguing are the challenges that come with a virtual visit. According to the survey, providers noted the following distractions:
A patient plucking their eyebrows during the appointment, not realizing the video was on;
Patients taking video calls while using the bathroom;
A cat jumping on a client's head during hypnosis;
A patient rollerblading on the beach during an appointment; and
Children interacting while their parents were meeting virtually with a care provider, either with the parent (playing peek-a-boo) or talking to the provider.
And patients weren't the only transgressors. According to the survey, patients noted the following issues with their care providers:
A provider with a frozen video screen, which the patient mistook for an "impressively focused, intense gaze;"
An unmade bed in the background;
A provider conducting the virtual visit from his car;
A provider's cat grooming itself for 45 minutes in the background; and
Meeting a provider's "really cute!" pet parrot.
Those observations point to the value of educating both patients and providers on how to conduct a virtual visit. Health systems should be training their care providers on how to present themselves during a virtual visit, and they should also be communicating to their patients how those visits should be handled on that end.
That said, telehealth can give the care provider an opportunity to see the patient's home environment and routines, which can factor into both diagnosis and treatment. According to the survey of providers, 36% reported seeing a patient's pet, 31% saw a family member or roommate, and 42% saw a patient outside of the house.
Healthcare providers have often said that a telehealth visit with the patient in his or her home can offer insights into habits and lifestyle that aren't seen or talked about in in-person visits, and which can affect healthcare delivery and outcomes. For example, a mental healthcare provider might be able to see certain stressors in the home that affect a patient's mental health, while a doctor treating a patient living with diabetes might gain better insight into how that patient eats and exercises each day.
Aside from pointing out the benefits and challenges of seeing patients and care providers via video, the Zocdoc study highlights the importance of treating telehealth as a part of the healthcare process, not as a replacement for in-person care. The platform offers certain advantages, with patients reporting that it's convenient and can eliminate the burden of taking time off from work or school, hopping in the car or taking a bus and travelling to a doctor's office.
But it's not always the right mode of care, with providers opining that it doesn't allow them to fully examine a patient. According to the survey, 58 percent of providers said it was more difficult or much more difficult to examine patients, and a quarter said it wasn't possible to provide the type of care patients expect via telehealth. Some 37% of providers said it was more difficult or much more difficult to build a relationship with patients via telehealth, and only 7% said it was easier (interestingly, 31% or patients felt it was easier to build a relationship with a provider via telehealth, saying the decreased level of formality in a virtual visit enabled them to be more comfortable).
The path for health system executives going forward is to highlight the benefits of telehealth and present that as an option to in-person care when appropriate, and to point out that telehealth can support in-person care but doesn't have to replace it.
Compelled by consumers who don't always want to schedule a video visit or drive to the doctor's office or ER, health systems are finding new value in asynchronous, or store-and-forward, telehealth.
Not every telehealth encounter has to include video, or even be a real-time conversation. Many healthcare organizations are finding that an asynchronous – also called store-and-forward – platform works better for certain services.
"It can be a very simple, efficient format for what we want to do," says Brett Oliver, MD, chief medical information officer for Baptist Health, an eight-hospital, 400-site health system based in Louisville, Kentucky serving parts of Illinois, Indiana, and Tennessee. "And that's what our patients really want."
Unlike synchronous telehealth, which basically consists of a two-way, real-time audio-video feed between patient and care provider, asynchronous telehealth doesn't involve real-time communication, and most often doesn't include video. Consumers enter information into an online platform at their own time and convenience, usually through a questionnaire, and a care provider accesses that data on the other end then responds with a diagnosis and treatment plan. It can be done by phone or computer and include images and even video, but the key factor is that both patient and provider can access the platform at the time and place of their choosing.
Asynchronous telehealth has proven popular in direct-to-consumer programs and for services that don't rely on immediacy or direct communication. It's often used for acute care concerns for someone who might visit the doctor's office, an emergency care clinic, or the emergency room for, but which aren’t critical enough to merit hands-on care, such as infections, rashes, colds, and viruses. In fact, numerous health systems dealing with crowded ERs have used asynchronous telehealth platforms to reduce ER traffic and give patients an easier way to seek care at home.
Moving Beyond the Pandemic
At Baptist Health, Oliver said the health system leaned on its asynchronous eVisit platform during the pandemic, when ER traffic was heavy, hospitals were struggling with both capacity and workforce issues, and there was a strong need to separate infected patients from uninfected patients and staff.
"It was a real eye-opener for us," he says.
Brett Oliver, MD, chief medical information officer for Baptist Health. Photo courtesy Baptist Health.
With the pandemic fading, the health system has seen steady interest in the platform, an indication that asynchronous telehealth has a place in Baptist Health's roster of services, alongside both in-person and video visits.
"Our patients want this," Oliver says. "And if we don't have it, they'll go elsewhere."
Baptist Health isn't a unique case. Asynchronous telehealth had been enjoying some success prior to COVID-19, especially in populous areas where the market for non-urgent walk-in care was intense. But many health systems were hesitant to adopt a service that didn't include video, and federal and state regulations were much more restrictive, and in some cases prohibited use of the technology altogether. The pandemic changed that, as state and federal regulators relaxed the rules to increase coverage of and access to telehealth and health systems willing to give it a try.
Oliver says Baptist Health had created a centralized hub for nurse practitioners to handle asynchronous telehealth visits, building the platform out of an old retail clinic program that hadn't worked. They built the program on their Epic EHR infrastructure, partnering with telemedicine vendor Bright.md.
Prior to the pandemic, he says, the asynchronous service saw limited use, but COVID-19 changed the public's perception on how it wanted healthcare access. Primary care had always been somewhat of a challenge for Baptist Health and its patients, many of whom live in rural areas, but a platform that allowed them to connect with a care provider at their own convenience, rather than driving somewhere or finding the time to sit down in front of a computer for a video visit, hit the mark.
Oliver says many people are more comfortable talking about their health in this format, rather than through a video or even in person. They're less self-conscious, and usually focused on getting quick and easy treatment for a nagging health concern that isn't serious enough to merit a traditional healthcare visit. A post-visit survey of patients found that one in every four or five would have gone to an ER had they not been able to use an eVisit, he says.
"A lot of people didn't know about asynchronous," he says, noting they handle about 100 cases per week, down from a high of 300 during the height of the pandemic. "Now they don't want to go without it. They feel this is personalized care even though it doesn't have video."
The process is fairly simple. Consumers fill out a questionnaire, which takes roughly 12-15 minutes, which is screened by an NP and forwarded to a clinician. The clinician reviews the information within the EHR, then submits a diagnosis and care plan where appropriate. The health system promises a response within two hours, but usually gets back in touch within 15 minutes.
Oliver says the encounter can be ramped up at any time to include a video visit or a recommendation that the patient visit a doctor. The questions in the questionnaire are also fine-tuned to make it easier for the NPs to refer cases to the right clinician, and the health system is setting aside time to update and add questions to enable them to treat more health concerns.
According to Oliver, almost 90% of the patients seen and treated via the platform don’t seek additional care within 30 days, which means they're getting the care they need. The health system is also reporting a patient satisfaction rate well above 90%.
That information will be important to track and collect, he says, to convince payers that asynchronous telehealth should be a covered service. Like so many other health systems, Baptist Health isn't being reimbursed for these services, and instead charges users a flat fee, which may hinder adoption by the Medicare and Medicaid populations.
Securing Provider Support
Another key benefit to this platform is that it improves efficiency for the provider. But it took some time for the providers to realize that.
"It really was a learning curve for us," Oliver says of the effort to secure provider buy-in. "A lot of them hadn't used this before, and so their first thought was, 'Are you taking something away from me?' They're used to seeing patients because that's how they're paid."
But just as it's more convenient for patients, this platform also fits nicely into the clinician workflow. They can sit down, review all the data on hand, research any nagging questions, and send the patient a diagnosis and care plan in less time than it would take to schedule and complete a video or in-person appointment, and they can bump the encounter up to a video visit or in-person treatment if one is needed.
"About 95% of the diagnoses can be done right after reviewing the patient's information," Oliver says. This tells him not only that the health system is seeing the right patients on that platform, but that it's choosing the right conditions to treat on that platform, and not funneling patients there who end up needing more complex or advanced care.
Aside from adding more health concerns that can be covered in an asynchronous visit, Oliver sees more room for expansion on the platform. He'd like to include chronic care management to enable patients and their care providers to keep in contact between scheduled appointments, as well as wellness visits and follow-ups after inpatient services. In that sense, the platform could be used as a remote patient monitoring program.
"It allows us more touchpoints with our patients," he says. "We need to think about and be able to use different modes of care delivery."
A three-year study in rural Alaska has shown that a telehealth program can help children access specialist services for hearing issues much better than the traditional in-person referral process.
A telehealth program in Alaska that enabled rural children to access hearing specialists is proof that the platform can reduce rural disparities in access to care, according to supporters.
The Hearing Norton Sound study, conducted in 15 rural Alaskan communities from 2017-20, allowed children to connect with specialists for diagnosis and treatment of hearing problems. Roughly 1,500 children in the Bering Strait School District in the northwest part of the state participated in the study, and those using telehealth were treated to follow-up care 17.6% faster than those receiving standard primary care referrals.
According to the study, participating students were split into two groups, with one group accessing specialists via telehealth and the other group being referred for in-person follow-ups. Almost 70% of those using virtual care were able to meet with specialists, researchers said, while only 30% in the other group were able to get follow-up care.
“Childhood hearing loss has well known, profound implications for language development, school achievement and future employment opportunities,” the study reported. “Some populations experience a disproportionately high burden of childhood hearing loss, including rural Alaska Native children, among whom there is a prevalence of up to 31% compared with 1.7-5% in the general US population.”
Emmett, an associate professor in the UAMS College of Medicine Department of Otolaryngology-Head and Neck Surgery and the Fay W. Boozman College of Public Health Department of Epidemiology, partnered with Samantha Kleindienst Robler, PhD, AuD, the Center for Hearing Health Equity's associate director and an assistant professor in the UAMS College of Medicine Department of Otolaryngology-Head and Neck Surgery, on the study. Robler is also a population health researcher at the Norton Sound Health Corporation, a tribally owned and operated independent not-for-profit organization that served as the tribal health partner for the study.
The study targets a common barrier to care in rural parts of the country: a lack of specialists, many of which are clustered around urban areas and cities. To address this imbalance, health systems are setting up telemedicine platforms that allow them to connect with rural providers, such as health clinics and primary care providers, and provide specialists for virtual visits.
Emmett said the study, which was recently published in The Lancet, has implications for any rural part of the country, if not the world, where access to specialists is infrequent and challenging.
“Even if children are identified with hearing loss at school, they often never receive the care that they need," she said. "This loss to follow-up from school screening programs, as well as a dearth of specialists in rural areas, exacerbate barriers to care for rural children."
“The purpose of this study was to test whether telemedicine can address this challenge, providing a way for rural children to promptly enter the health care system to receive the specialty care they need,” she added.
The Los Angeles-based health system is using a $7 million federal grant to expand a digital health program that will develop AI tools to help providers analyze a patient's risk of heart attack and other cardiac concerns.
Cedars-Sinai researchers have received a federal grant to study how AI can be used to help predict heart attacks and other cardiac concerns.
A team from the Los Angeles health system's Smidt Heart Institute and Division of Artificial Intelligence in Medicine is using a $7 million grant from the National Institutes of Health's National Heart, Lung and Blood Institute to set up the new program, which will use data from positron emission tomography and CT scans to analyze a patient's risk of cardiac issues.
“Advanced imaging data could help predict patients’ risk of serious cardiac events, but is so complex that clinicians aren’t always able to use it,” Piotr Slomka, PhD, director of Innovation in Imaging and professor of Cardiology and Medicine in the Division of Artificial Intelligence in Medicine at Cedars-Sinai and the lead researcher in the project, said in a press release. “This grant will allow us to create artificial intelligence tools that help physicians everywhere identify high-risk patients who would benefit from targeted therapy.”
According to the American Heart Association, more than 18 million people died of cardiovascular disease in 2019. Many healthcare organizations are looking to digital health to develop new ways to detect cardiac problems early enough for care providers to intervene before they become serious, even deadly.
Cedars-Sinai has long been at the forefront of digital health innovation, working with tools like virtual reality, wearables and AI to improve treatments and clinical outcomes. This past March, researchers in the quantitative image analysis lab at the Biomedical Research Institute announced the development of an AI tool that analyzes the amount and composition of plaque in arteries that supply blood to the heart to determine heart attack risk within five years.
“A deep learning system that rapidly and accurately quantifies coronary artery stenosis has the potential for integration into routine CCTA (coronary CT angiography) workflow, where it could function as a second reader and clinical decision support tool,” the research team reported in a study published in The Lancet. “By providing automated and objective results, deep learning could reduce interobserver variability and interpretative error among physicians. Deep learning-based plaque volume measurements have independent prognostic value for future cardiac events, and could enhance risk stratification in patients with stable chest pain who are undergoing CCTA.”
With this latest program, Slomka and his team plan on expanding the platform.
“This particular grant allows us to build a program—not just a project—which will expedite our innovative plans,” he said in the press release. “In AI, things are changing all the time, and sometimes we find that we could make much more impact if we change direction. The beauty of this grant is that it makes that easy to do.”
Nanotechnology is moving from fiction to reality, with at least two universities studying the use of miniature robots inside the body to treat diseases and address other health concerns.
Fans of Fantastic Voyage take heart: The innovative nanotechnology featured in the 1966 movie about miniaturized doctors entering a human body may actually be coming true—sort of.
Researchers at both Stanford University and Purdue University have recently published studies on the use of miniaturized robots inserted into the body to treat certain health concerns. The robots could be used to delivered timed doses of medicine, chart the course of a tumor or disease, or even remove obstructions such as blood clots.
While nanotechnology has long been a popular topic in fiction, from Michael Crichton's 2003 novel Prey to the most recent James Bond movie No Time to Die, it's starting to show up in the real world. Several programs over the past few years have focused on the development of pills fitted with digital health sensors that are ingested and used to deliver timed doses of medicine and/or track vital signs and medication results, though the digital health company best known for developing that technology, Proteus, filed for bankruptcy in 2020.
Now some researchers are trying a new delivery method.
At Purdue, "microbots" developed by Hyowon "Hugh" Lee, an associate professor from the Weldon School of Biomedical Engineering, have been used to remove blood accumulating around the brain after a stroke. Working with neurosurgeons Timothy Bentley, MD, of Purdue's College of Veterinary Medicine, and Albert Lee, MD, from Goodman Campbell Brain and Spine in Carmel, Indiana, he successfully removed pooled blood in six of seven animals.
"This innovation is a real advance in the care of strokes, which are notoriously difficult to treat," Lee, whose work was recently profiled in Nature Communications, said in a press release. "Patients with brain hemorrhages have a mortality rate of up to 50%. Currently there is no great therapeutic solution for intraventricular hemorrhage. The only other option is blood clot-dissolving drugs that have undesirable risks."
At Stanford, meanwhile, Renee Zhao, an assistant professor of mechanical engineering, is working on "millirobots," or fingertip-sized biomedical robots that move through the body on magnetic fields. As noted in a study in Science Advances, her "spinning-enabled wireless amphibious origami millibot" is designed to "crawl, spin or swim" through the body until it reaches its target, then release a high-concentration drug.
In a news story issued by Stanford, Zhao and her team say the technology "won’t just provide a handy way to effectively dispense medicine but could also be used to carry instruments or cameras into the body, changing how doctors examine patients."
"While we won’t see millirobots like Zhao’s in real healthcare settings until more is known about optimal design and imaging best practices, the lab’s first-of-its-kind swimmer … is among their robots that are furthest along," the press release continues. "It’s currently in the trial stages that come before any live animal testing that proceeds human clinical trials."
Boise State University and the University of Utah are collaborating on a new program that will use virtual reality to help medical students identify and address social determinants of health.
A new project being launched at Boise State University and the University of Utah aims to use virtual reality to train medical students how to talk to their patients about social determinants of health.
Boise State School of Nursing Associate Professor Kate Doyon and co-investigators Nancy Allen and Julie Gee, associate professors at the University of Utah’s College of Nursing, will be working with the Spencer S. Eccles Health Sciences Library and Therapeutic Games & Applications Lab to create VR platforms that will teach future doctors, nurses, dentists and social workers how to talk to patients about non-clinical barriers that may affect their ability to access care or follow care plans.
“As providers, we have to know what the barriers and facilitators are to get [patients] on a plan of care,” Doyon said in a press release issued by Boise State. “It should be routine to ask the patient about their world.”
“At the end of the day a plan must be patient-centered,” she said, she added.
Social determinants of health can have a profound effect on clinical outcomes by hindering or even preventing consumers from getting the healthcare services they need. These barriers include family and job support, socio-economic and cultural norms, language issues, physical and geographical obstacles and digital literacy.
Supported by a $100,000 grant from the University of Utah's VR4 Health Sciences Education program, the project will create VR scenarios that allow students to see how these barriers, such as lack of access to a pharmacy or a home life that isn't conducive to post-discharge recovery, affect care management and coordination.
“The more realistic we can make the [virtual reality simulation], the more of an impact we can have,” said Doyon, who plans on seeking funding from the National Institutes of Health.
Healthcare experts say that by identifying the social determinants of health, providers can develop more comprehensive care coordination and management plans that overcome those barriers to care and boost health and wellness. That might include helping consumers understand how to use telehealth and digital health, arranging transportation to and from medical appointments or offering resources to address food insecurity, exercise, legal and family issues, even budgeting and housing concerns.
The Health and Human Services Department's Office for Civil Rights has released guidelines on how healthcare providers can use audio-only telehealth platforms, including the phone, that meet requirements set forth by the Health Insurance Portability and Accountability Act.
Federal officials are cracking down on healthcare organizations using audio-only telehealth platforms – such as the telephone – to deliver healthcare services.
The Health and Human Services Department's Office for Civil Rights (OCR) has released guidance on how providers can use "remote communication technologies to provide audio-only telehealth services" without running afoul of the Health Insurance Portability and Accountability Act (HIPAA), which focuses on how sensitive health information is disclosed over various communications channels.
“Audio telehealth is an important tool to reach patients in rural communities, individuals with disabilities, and others seeking the convenience of remote options," OCR Director Lisa J. Pino said in a press release. "This guidance explains how the HIPAA Rules permit health care providers and plans to offer audio telehealth while protecting the privacy and security of individuals’ health information.”
Audio-only telehealth platforms have been heavily regulated in the past, and in many cases healthcare providers aren't permitted to conduct healthcare via that technology. But during the pandemic, which forced providers to move away from in-person services and conduct more business via telehealth, the federal government issued a series of waivers, including one on HIPAA enforcement, aimed at expanding telehealth use and coverage.
Telehealth advocates have noted that the pandemic has proven the value of audio-only telehealth, particularly in rural and remote areas and for people who don't have access to audio-visual telemedicine platforms or rely on the telephone as their only means of communication. While the federal waivers are scheduled to end with the public health emergency (PHE), some states have already taken action to permit the use of audio-only telehealth for certain services, and several bills before Congress aim to make those freedoms permanent and nationwide.
The OCR guidance serves to remind healthcare organizations that they need to be careful how they use audio-only telehealth during the public health emergency, and that those rules will tighten when the PHE ends.
