An initiative launched in 2021 out of the University of Chicago Health Labs has released recommendations aimed at upgrading the nation's 54-year-old 911 Emergency Response System, including developing technology and training standards and creating a Cabinet-level post to oversee the network.
A collection of healthcare stakeholders has released a policy blueprint aimed at updating and improving the nation's 911 Emergency Response System, with recommendations that range from establishing a Cabinet-level position to setting standards for new and innovative technology.
Transform911, an initiative launched in 2021 with more than $1 million in funding, led by the University of Chicago Health Lab and comprised of more than 100 stakeholders, has unveiled six key recommendations, the result of 18 months of meetings and research into the 54-year-old emergency response network.
“It’s clear that the times call for the most comprehensive overhaul of the nation’s 911 system ever, to ensure that the right professional responds to an emergency call at the right time,” S. Rebecca Neusteter, PhD, executive director of the University of Chicago Health Lab and principal investigator of Transform911, said in a press release. “Recent events highlight that policymakers at all levels of government must identify, debate, and implement changes to the emergency response system. It’s a matter of life or death.”
The group has issued the following recommendations:
Create a Cabinet-level position within the US government to report to the President on urgent 911 improvements;
Create a federal task force to set standards for new technology, including digital health and telemedicine platforms and tools, and addressing such concerns as security and privacy of 911 calls and data;
Create protocols for training and access to technology to ensure that the nation's 911 workforce is well-resourced and trained;
Create a separate governance structure for 911 centers so that they're independent and equal to police, fire, EMS and other public safety entities, giving them the autonomy to address and report on public safety issues as they see fit;
Integrate community perspectives into 911 policies so that 911 centers can better understand and build relationships with different members of the community – especially minorities, who may not trust the system or believe it's equitable; and
Re-introduce the 911 network to the American public, with an awareness campaign that highlights the training and capabilities on 911 centers and tackles the misconception that "911 is a switchboard service staffed by operators."
According to the group, the nation's more than 6,000 911 centers function through a patchwork of governance structures over seen by local, state, and federal agencies. There are no common standards at present for how these centers select and train their staff, use technology, collect and report on data, or ensure quality and security. This also means there isn't that much federal support or funding to make improvements.
Much has changed in the half-century that 911 centers have operated, including recent efforts to better determine who should be dispatched to 911 calls (for example, replacing police as first responders with trained mental health crisis professionals or – in mobile integrated health programs - specially trained paramedics).
New technology is also improving the 911 process, through telemedicine platforms and digital health tools that enable 911 centers to coordinate emergency care through virtual channels, bypassing a trip to the ER when that's not the best option, or enable first responders to access resources and connect with healthcare specialists.
“The time to update and transform the emergency response model in the United States is now,” Walter Katz, vice president of criminal justice at Arnold Ventures, a philanthropy that is helping to finance Transform911, said in the press release. “Local communities and the country need a comprehensive, transparent, and innovative approach to strengthen the 911 system. These recommendations help establish a more effective, equitable, uniform emergency response that protects public health and safety.”
Along with Arnold Ventures, the group is supported by the Microsoft Justice Reform Initiative, the Sozosei Foundation, and the Wagner Foundation. Other partners in the project include Code For America, the Full Frame Initiative, the New York University School of Law's Policing Project, and the Research Triangle Institute (RTI) Center for Policing Research and Investigative Science.
The Delaware health system and two digital health companies have joined forces to create a digital health platform that will allow college students to access a wide range of services, including primary care, physical rehabilitation and mental health and substance abuse care, from their computer or mobile device.
ChristianaCare is launching a bundled virtual care program aimed at helping college-aged students easily access a wide range of healthcare services ranging from primary care and physical therapy through mental health and addiction treatment.
The Delaware health system is partnering with digital health providers PursueCare and SimpleTherapy to create the program, which offers a single digital portal, accessible via an mHealth app on mobile devices and computers, through which students can connect with internal and family medicine providers from ChristianaCare's Center for Virtual Health.
The platform will also allow students to access mental health, psychiatric and medication-assisted treatment providers affiliated with PursueCare and physical therapists affiliated with SimpleTherapy and specializing in musculoskeletal care, acute or chronic pain management, and strength and mobility training.
The new program targets students who have problems accessing healthcare, particularly for sensitive issues like mental health concerns are substance abuse. They may be far from home, unable to get in touch with their primary care provider and either too busy or hesitant to visit the health center on campus.
“When college students are able to access medical, behavioral health and musculoskeletal services through their phone or laptop, from their dorm room or a private space on campus, they’ll be more likely to get help when they need it," Sharon Anderson, MS, RN, FACHE, ChristianaCare’s chief virtual health officer and president of ChristianaCare’s Center for Virtual Health, said in a press release. "This is about delivering care to students on their terms, so that they can be healthy and supported with high-quality care throughout their college experience.”
The program also fits a need for colleges and universities who are struggling to address a nationwide surge in mental health and substance abuse cases, and an increase in student suicides. While many are beefing up services through their health center, digital health and telehealth partnerships with health systems and specialty care providers offer another avenue to improve access to care.
“For college and university student health services and administrators, this partnership offers a powerful new way to provide comprehensive, affordable health solutions that benefit students,” Anderson said. “In a highly competitive recruiting environment, these solutions are easy to implement and can add tremendous value."
The platform enables students to access digital health resources, assessments and virtual care modules at any time, as well as connecting via a telemedicine portal to care providers. They'll also be able to use the PursueCareRx portal for pharmacy services.
Participating colleges and universities will be able to offer the branded program to students for a flat fee, enabling them to access the portal whenever and as many times as they need help.
The program is currently licensed to operate in Delaware, New Jersey, Pennsylvania, and Maryland, with plans to expand to other states.
Henry Ford Innovations is partnering with digital health company Exo to apply digital health concepts to ultrasounds, with the goal of making them more portable and accessible to underserved populations.
Henry Ford Health is partnering with a digital health company to make ultrasounds more portable and accessible.
Henry Ford Innovations, the Michigan-based health system's innovation arm, is working with Exo, a California-based developer of point-of-care ultrasound (POCUS) technology with a connected software platform. The project aims to bring ultrasounds, which are traditionally conducted in hospitals and medical offices, out to remote and underserved communities, where they can tackle traditional barriers to care.
"We envision a future where handheld portable ultrasound is as ubiquitous as the stethoscope, only more accurate and more capable," Dan Siegel, MD, a musculoskeletal radiologist and vice chairman of radiology quality and informatics at Henry Ford Health, said in e-mail. The technology, he said, would be "able to provide quantitative data and faster, more automated assessment for our patients and providers."
"Through this partnership, we are focused on improving [three] things," he said. "The first is education and training, making sure that all users who have a handheld probe are appropriately trained and credentialed to do appropriate high-quality scans. The second is system-wide standardization, where any clinical scan is performed according to appropriate parameters, annotated and documented in a standardized high-quality method, and stored in a common environment that is easily accessible by any provider or the patient. And finally, to research advanced techniques using machine learning and AI to automate or accelerate the acquisition of images, quantitative assessment of those images, or the automated interpretation of those images to make the learning curve faster for novice users, or users in non-traditional environments [such as] home care and remote medicine."
Siegel said POCUS technology allows care providers to treat patients more comfortable and quickly and wherever patient and provider are located, speeding up the diagnosis and the care plan.
"Instead of having to wait for additional test results, providers can use what they have in their pocket to get near-instantaneous data that can inform clinical decisions right at the point of care," he said. "This is already happening with home care and the mobile integrated health program, helping decide at the point of care in patients' homes whether they are safe to stay at home or not."
"We really see this as just scratching the surface," he concluded. "Ultrasound is such a powerful tool, and the technology continues to get smaller, with higher image quality and less cost. We really do believe this will be the stethoscope of the future, and as more and more young and early-stage clinicians (and students) become familiar with the tool, we will see more and more research around what can be done in novel and unusual clinical settings. All of this will produce substantial benefits for our patients and providers, and for the system as a whole."
The Florida-based health system will use the wayfinding platform to create the foundation for a more extensive patient portal.
Being a kid, or a parent of a kid, in a hospital is an extremely stressful experience and pediatric hospitals are turning to innovative technology to reduce that tension.
At the Nicklaus Children's Health System in Miami, officials have introduced a wayfinding platform and accompanying app to help patients and visitors find their way around the 309-bed hospital and associated care sites, such as doctor's offices and urgent care centers. The resource not only maps their healthcare journey, but helps them locate such amenities as the cafeteria, gift shop, pharmacy, restrooms, and even ATMs.
Hospital leadership says the wayfinding platform is a first step—literally and figuratively—toward a much larger digital health experience.
"This is how we become a connected healthcare provider," says David Seo, MD, the health system's vice president and chief digital and information officer. "We have been wondering how can we use digital health technology to improve the experience for families, and this is our initial foray into that digital experience."
The health system is partnering with Atlanta-based Gozio Health on the platform, accessible through the MyNicklaus App. The platform uses digital health technology similar to a GPS system to give users turn-by-turn directions to their destination, whether it's down the hall or another building on the other side of the city.
While health systems try to make it as easy as possible to get around—think color-coded lines on the floor, maps, signs, and information booths—they can only do so much for what are often stressed-out visitors. And the typical healthcare campus or system has grown, encompassing multiple buildings and sites.
Wayfinding platforms, which can be accessed on a visitor's smartphone or tablet, can be an invaluable resource, and a strong statement toward improving the patient experience. They not only help put visitors at ease but help ensure that patients make scheduled appointments, ensuring care management plans are met, and physician workflows aren't interrupted.
At Nicklaus Children's, Seo sees the platform as the foundation for a much more intricate patient portal, one that can serve as the patient's front door to healthcare.
"This can be more than just a platform for wayfinding," he says. "There's a lot that we can connect to this to improve the patient experience. We are in the midst of a massive consumerization of healthcare … and this is what people have come to expect from us. We want their experience to be as smooth and frictionless as possible."
Nicklaus Children's isn't unique in this strategy. Many health systems across the country are using a tiered approach to developing a patient portal, so that they don't overwhelm either their patients or their staff with new technology and services. The idea is to roll out one service, such as wayfinding, allow some time for everyone to get used to the platform, then gradually add other services to that platform.
"This is our initial foray into the digital experience for patients," Seo says. "We want to make sure we get this right before we move on."
That means making it as convenient for the staff as for the patients. Seo says a wayfinding platform had always been a priority for hospital staff, not just for their own use but as a tool for improved patient engagement. Care providers have a vested interest in making sure patients get to where they need to be in the healthcare system, to reduce the stress and annoyance of missed appointments and to make sure patients are on the best care management path.
Success will be measured in use. Seo says the health system will be keeping close tabs on who uses the platform, how often, and whether it gets people to where they need to be (measured, of course, in the number of no shows and late arrivals for appointments.) They'll also make sure the platform is accurate, in that it's giving detailed and accurate directions and not sending anyone astray. That means making sure every location in the health system is accurately mapped, the cafeteria is open, the ATM or the bathroom is actually right around the next corner, and the doctor's office is where it should be.
"It's not as simple as it seems," says Seo. "It's complicated, and it needs to be intuitive. We need to make sure the overall platform is very contextually aware of [how the health system delivers healthcare services.] It's important that this be a part of how we conduct business, not just be an add-on."
Once both visitors and staff get used to using the app to find their way around the health system, Seo says they'll look to add other services, such as registration, health records access, insurance verification, communications and scheduling tools, even virtual visits. He wants this to be a portal, through which patients and their families access information, talk to care teams, and schedule their visit to the health system before it takes place.
"This is what we're moving toward in healthcare," he says. "This is what people are beginning to expect, and we want to give them that intuitive, seamless experience."
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.
