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Virtual care in the time of COVID-19

Healthcare is forced to go virtual — here’s what that means and how it helps

It’s a problem — a big problem. Our healthcare system is built to care for millions of patients through in-person clinic visits, but, now, the very visits required to manage the health of those patients can lead to serious complications from COVID-19.

Without supportive care for chronic illness, millions of patients may experience a decline over the next few months. Besides the first and possible second wave of COVID-19 infections, we will see a third wave of illness in the form of chronic disease complications — unless we can rapidly stand-up a national virtual-care strategy.

A virtual-care strategy must include effective elements from telehealth, telemedicine, remote-patient monitoring (RPM), and digital chronic disease management (DCM).

Lucky for us, the technology and expertise exist to do this type of large scale implementation — it just requires a concerted effort to pay for, de-regulate, and invest in these services.

You may be hearing some new words thrown around due to the COVID-19 pandemic. Telehealth, telemedicine, remote patient monitoring (RPM), virtual care, and digital health have been around for years, but the recent situation is accelerating patient awareness and physician adoption of these technologies.

With a growing need for social isolation, healthcare organizations are actively seeking ways to provide health services to patients with both COVID-19 and other conditions remotely.

These buzz words all fall under growing movement in healthcare — the digital health movement. In 2019, $8.9 billion was poured into digital health companies by venture capital firms. The Health Information Management Systems Society (HIMSS) defines digital health as:

“Digital health connects and empowers people and populations to manage health and wellness, augmented by accessible and supportive provider teams working within flexible, integrated, interoperable and digitally-enabled care environments that strategically leverage digital tools, technologies and services to transform care delivery.”

For those who do not speak “healthcare,” the goal of digital health is the better use of information and communication technology to improve the delivery of healthcare to patients and to arm patients with their own data to help them attain better health.

This was happening before COVID-19

If you take a moment to think about our national healthcare system you will quickly realize that things are not good. Cost is out of control, our outcomes are comparatively worse than other developed nations, and our individual stories tell powerful stories of failure.

If you think about your most recent experience with your physician, you probably had to make a trip to the office where you may have spent considerable time in a waiting room despite having an appointment. You may have filled out the same paper forms and used your hard-copy insurance card for payment. You may have two separate doctors who fax records to each other or do not communicate at all. Your prescription may have gotten lost on the way to the pharmacy.

Once you get into the exam room your doctor may ask you questions about how you are feeling, your lifestyle, your medications, your diet, and may perform bloodwork or other tests. All this information is recorded in a record that may be paper or electronic. Once recorded, it is up to your physician to analyze the information to produce a diagnosis or treatment plan.

Your 15-minutes with the physician with an hour of waiting really does not feel like a good use of your time and you do not have a better handle on your health once its all over.

Once all the tests and questions are answered, you may be sent home to wait for a call, or asked to return to the office for a follow-up. You also may be diagnosed in the office if results are fast enough. Either way, you and your physician will eventually arrive at a plan for treatment.

Your treatment plan likely includes some form of medication, lifestyle changes, exercise regimen, and dietary changes. It may be told to you verbally, or it may be handed to you on a piece of paper. You then leave the office, pick up your prescriptions, and must navigate your new diagnosis and care on your own until the next appointment — which may be a few months away.

You may have received new medications to add to your daily list. Medications are the cornerstone of treatment for many conditions but are also dangerous due to their significant impact on body systems. Your physician may not have checked your entire medication list despite the importance of a thorough medication review.

In that 15-minute meeting with your healthcare provider, you may have a lot of questions, you may not understand what is going on, and you may have questions about your healthcare. You may be worried that things aren’t getting better and you have no way to know if what you are doing is working.

But, things have been changing.

Digital health seeks to enhance administrative tools, clinical tools, and patient interaction to make the healthcare experience more effective, efficient, and positive for patients. Healthcare is far behind in technology, and this industry is looking to fill that gap.

Those of us who work in the digital health space want to take your current healthcare experience which is something like Blockbuster Video in the early 2000s and turn it into Netflix.

We want to give you access to physicians via video chat on your mobile phone — that's telehealth or telemedicine. We want you to schedule appointments online rather than over the phone, we want to provide your lab results and tests through an app quickly rather than via paper, and we want to keep you out of waiting rooms. In short, we want to make your experience as friendly, effective, and efficient as possible.

Taking it a step further, many of the companies that fall under the umbrella of digital health want to not only improve patient access to care and experience but the actual outcomes for patients — they want to create technologies and models of care delivery that are more effective than the old model explained above.

To do that, it requires the effective use of patient data, patient-clinician communication, and the empowerment of patients. Out of these goals, remote-patient monitoring and digital care management were born.

But, now, with COVID-19, the ability to digitize and facilitate remote care services is an issue of national proportions.

Mobile-technology has made this possible

These concepts have grown out of the recent acceleration of mobile and wireless technology. Now, according to 2019 PEW survey data, 81% of the U.S. population in total has some form of smartphone (Table 1).

Table 1. Mobile Devices in the U.S. Population

With technology now enabling the quick and mobile collection, exchange, and analysis of data as little computers with us at all times, a major interest has developed in using the technology in the healthcare industry — thus, digital health.

The digital revolution has raged in other industries. The emergence of Netflix in media and Amazon in retail grew out of the same trends and technologies. But, healthcare has been much slower to adopt —and is ripe for major digital disruption.

Now that digital has become a big part of daily life, patients and health professionals are starting to gain awareness of digital solutions that both enhance and threaten the traditional models of health services.

When I talk about digital health, I usually break the major benefits down into four buckets: data collection, analytics and automation, communication, and patient experience.

Technology now allows for better data collection, enhanced analysis and automation of data-related activities, improved communication (video chat, messaging, email), and overall a better more convenient, and accessible patient experience.

During COVID-19, it is imperative that we are able to leverage these technologies to provide effective, real-time healthcare services in the home.

Virtual care has shown big benefits for patients

Beyond the video conferencing with your physician that is telehealth. There are more robust services like RPM and digital care management. These, combined with telehealth, are more focused on real-time data collection, treatment plan optimization, and chronic disease “coaching” to help patients stay on track, to step in if the deterioration is detected, and to act as a supportive resource as patients navigate the management of their conditions.

There are benefits in terms of patient self-efficacy, convenience, and patient engagement which are all beneficial.

Prior to COVID-19, evidence shows positive outcomes from RPM, DCM, and telehealth programs.

In a large scientific review of telehealth and virtual care, the Agency for Health Research and Quality found big benefits in the pre-COVID-19 period. The most consistent benefits are seen when telehealth is used for communication and counseling or remote monitoring in chronic conditions such as cardiovascular and respiratory disease. The outcomes measured include improved mortality, a better quality of life, and reductions in hospital admissions [1].

In a 2018 review of RPM studies from 27 clinical trials, the general consensus is that these programs are effective — but there are mixed outcomes when looking at the entire field of solutions. This article found that programs with personalized coaching to promote good health behaviors and adherence were the most effective [2].

RPM programs have grown up around specific conditions with some of the most robust programs focused on congestive heart failure (CHF). In a 2019 study, one RPM program focused on CHF showed a 33% reduction in hospitalizations, a 75% reduction in 30-day readmissions, and a 52% reduction in emergency department visits [3]. Due to these reductions, significant cost savings were found.

For digital-enabled care management programs, there have been positive outcomes shown in clinical studies. In one 2017 study looking at a mobile application for diabetes control, patients tested their blood glucose more frequently and showed fewer hyperglycemic events and lower overall blood glucose levels [4].

We are still in the early stages of the virtual care revolution, but programs like remote-patient monitoring, digital chronic disease management, and

While telehealth has been around for decades, the integration of more engaging technology and better use of remote-clinical data is likely to lead to programs that can drive significant health outcomes.

Virtual care solutions are crucial for COVID-19 patients and patients with other conditions

The key to these programs is their “remote” nature. They allow for monitoring and connection to the patient without requiring physical contact.

With the growth of mobile technologies and IoT-enabled medical devices, the capacity to deliver services to patients through these mediums has grown exponentially over the previous 5 years.

It is crucial that we continue to invest in, de-regulate, and ensure payment for these services in the health system as we search for ways to manage the current public health crisis and beyond.

Robert L. Longyear III is the author of Innovating for Wellness, a book about innovation in healthcare covering health policy and digital health. He is VP of Digital Health and Innovation at Wanderly and a former Medicaid researcher focused on value-based payment, high-risk care coordination, and social determinants of health.

References:

[1] Totten AM, Womack DM, Eden KB, et al. Telehealth: Mapping the Evidence for Patient Outcomes From Systematic Reviews [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Jun. (Technical Briefs, №26.)

[2] Noah, B., Keller, M. S., Mosadeghi, S., Stein, L., Johl, S., Delshad, S., … Spiegel, B. M. R. (2018). Impact of remote patient monitoring on clinical outcomes: an updated meta-analysis of randomized controlled trials. Npj Digital Medicine, 1(1). doi: 10.1038/s41746–017–0002–4

[3] Freitag, T. B., Taylor, G., Wick, L., Cunningham, J., & Alexy, T. (2019). Novel Remote Patient Monitoring System Improves Key Outcomes. Journal of Cardiac Failure, 25(8). doi: 10.1016/j.cardfail.2019.07.298

[4] Offringa, R., Sheng, T., Parks, L., Clements, M., Kerr, D., & Greenfield, M. S. (2017). Digital Diabetes Management Application Improves Glycemic Outcomes in People With Type 1 and Type 2 Diabetes. Journal of Diabetes Science and Technology, 12(3), 701–708. doi: 10.1177/1932296817747291

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Robert L. Longyear III

Robert L. Longyear III

Co-Founder @ Avenue Health | VP Digital Health and Innovation @ Wanderly | Author of “Innovating for Wellness” | Healthcare Management and Policy @ GeorgetownU