I have been absent from your inbox for a few weeks because, for the first time since all this started, I contracted SARS-CoV-2. What started as a loss of my voice and a cough evolved into a significant sore throat, weakness, fatigue, and aches and pains for about a week and a half. For the first time, I was experiencing the very thing I had been writing about for years—it was, at the same time, a beautiful moment of discovery, a terrible time filled with empathy for those that came before me, and an opportunity for reflection.
I have seldom been sick in my adult life, so it was quite a shock to be knocked out of commission for a solid 10+ days. I laid in bed and managed to watch the entire collection of seasons of The Last Ship and The Orville (both of which were fantastic). To add insult to injury, my sickness also corresponded with the final, beautiful days of nice weather in Washington D.C., which, if you are familiar with DC, happens reliably twice a year in April and September. Naturally, given my penchant for healthcare technology and services innovation, I also spent time exploring the utility of remote-patient monitoring, telehealth, and home-based laboratory tests for this particular episode of care. I have a few thoughts for you to chew on here.
Naturally, I was a frequent user of home-based rapid antigen tests. The technology that enables the detection of disease in a convenient home-based package will provide significant leaps forward in the coming years for a wide range of conditions.
Remote-Patient Monitoring (RPM)
I operate a remote-patient monitoring company, Avenue Health, and, so, around my home, I have a rather wide assortment of RPM medical devices. From Apple Watches and Fitbits to home-based EKGs and blood pressure cuffs, I have them all—and, needless to say, I was able to use these tools to transmit data back to my care team. I, fortunately, did not experience any respiratory distress or concerning vitals, but for patients that are of high risk and those that unexpectedly begin experiencing significant decompensation, RPM-based clinical technologies are able to effectively alert care teams. While I have emerged unscathed to this point, it was an educational experience going from the “monitor-er” to the “monitor-ed.”
With respect to the Covid-19 use case, RPM programs are typically built in two types of orientation. One, for chronic care that is focused on education and driving long-term improvement in patient health—typically operated from the outpatient setting. There are still alerts generated by patients with out-of-range vitals, but the focus of the program is lifestyle improvements, medication adherence, patient education, and preventing/preempting deterioration via close monitoring.
The second orientation is often more focused on the prevention of acute episodes, each orientation has some mix of elements from the other, but the purpose of the acute-episode orientation is that of a targeted goal. For example, an RPM program built to prevent hospital readmissions for patients with congestive heart failure sets patients up at hospital discharge and then monitors patients, closely, for a few months afterward with the goal of preventing costly readmissions. Using connected scales and blood pressure cuffs, clinicians who receive the data from patients are able to use the information to more effectively determine the risk of readmission and to actively manage patient treatments to prevent it.
For non-clinical patients (most of them), having an objective measure of health status being reviewed by a trained clinician provides significant peace of mind. In both infectious disease situations and ongoing chronic care, these models are clinically effective, cash-flow positive for healthcare providers, and provide a competitive advantage with respect to attracting and retaining patients. Here is a great resource for anyone looking to learn more about RPM.
Telehealth
It is important to note that as far as Medicare is concerned RPM is not telehealth. It is, in fact, its own segment of clinical activities. Hence why I discuss these items in separate sections.
The argument for expanded access to and permanency of telehealth has been hammered home for the past few years, but I would be remiss if I did not mention that it is a really, really, really, bad idea to force patients to come into a clinic for evaluation and prescriptions when they are sick with a highly-infectious disease. I will say it again, louder this time. It is a really, really, really, really, bad idea to force patients to come into a clinic for evaluation and prescriptions when they are sick with a highly infectious disease. If I had walked into my primary care office waiting room without an n95 mask or even with one, I was infectious enough to infect people.
Equally, in the realm of hospital-acquired infections, it is also a really bad idea to mix Covid-19 patients and non-Covid-19 hospitalizations in the same facility. Imagine putting highly infectious patients in the same facility as patients who are already in the hospital and therefore at high risk for complications from Covid-19. Thus, given some degree of recognition of these threats early in the pandemic, the US began to accept telehealth and hospital-at-home models with more gusto than before. Despite the progress, which I see as positive, it is important to remember that hospital-acquired infections (HACs) were a major problem prior to the pandemic as well. And the same forces that are seeking to limit telehealth in the pre-pandemic world are back to their old tricks. It is essential that we continue to push for smart advances in the availability and use of telehealth technologies to improve patient care.
We are all patients at some time in our lives and we should all care about how our healthcare organizations protect us from harm.
As a brief aside on the topic of non-covid-19 HACs, when my mom was undergoing chemotherapy, inpatient, for leukemia, she acquired a number of fungal and bacterial infections as the treatment and cancer destroyed her immune system—these pathogens hang out in hospitals. While infections are a natural outcome of cancer treatment due to an obliterated immune system, we should not ignore the opportunity to solve these programs via innovative clinical care paradigms. Telehealth technologies allow for new care models via hospital-at-home models. The technology to enable these care models has existed for about a decade, yet, we only started moving in this direction during a pandemic driven by a single respiratory infectious disease. There are millions of patients each year that would benefit from better infection control in clinical care. Back in the good ole days, we had specific hospitals for tuberculosis—a highly infectious and dangerous disease. But, investments in separate buildings and real estate to quarantine patients are expensive—wouldn’t it be nice if we could offer care to patients from the comfort of their own, secluded, and isolated homes? That is telehealth—it’s not just Zooming with a doctor when you add remote-patient monitoring technologies and combine it with home-based care models.
It all seems pretty logical, so why do we still have to enter a building to receive healthcare services? Prior to the pandemic, the resistance to reimagining care pathways in favor of patients was tangible. Driven by outdated regulations in both states and at the federal level and by the financial interests of insurance companies and hospitals, innovation around how patients access care has historically advanced slowly. Changes to the standard brick-and-mortar office visit and a re-thinking of care journeys stood in the shadow of blockbuster pharmaceutical innovation. But, perhaps now, there is a glimmer of hope that the force of software ( that is, some might say, “eating the world”) will be an unstoppable force such as in other industries like finance and media.
Healthcare has a major complacency problem that is, hopefully, being turned on its head due to the catalyst that has been this pandemic. But, without continued advocacy for the reduction of regulatory barriers and policies that favor patients over those who benefit from the status quo, we will return to the limitations of brick-and-mortar-only care.
A Policy Comment on Telehealth, Competition, and Moats
The business of healthcare services has long viewed growth and revenue sustainability through the lens of monopolistic practices and price inflation. Hospitals became health systems through the M&A of outpatient clinics and the construction of ambulatory surgical centers in surrounding areas. Private specialty medical groups gained scale by amassing the limited supply of sub-specialists in their local geographic areas—therefore, market control via the management and ownership of supply. Physicians are locked into tight non-compete agreements to further manage the control of the supply of healthcare services. All of this is complete with a feckless Federal Trade Commission.
Enter telehealth technologies and software—things that travel great distances via the reach of the internet. Telehealth, when operated and launched by non-hospital entities, is a threat to brick-and-mortar geographic monopolies. With aggressive lobbying for the destruction of arbitrary state barriers to care via state-regulated physician license laws, telehealth advocates are seeking to destroy the “regulation moats” that have supported our nation’s hospitals and health systems wallets. When I can see a cardiologist online who lives in New York, while I reside in DC, Medstar (a major DC hospital system) is powerless to capture my visit revenue. Visit revenue, of course, that Medstar has painstakingly clawed for via M&A and real estate investment for decades.
While many of us believe that telehealth access and expansion are “a given” or even somewhat guaranteed due to the experience of the past two years, they are not.
Any argument against telehealth expansion and availability is one in favor of the higher prices and monopolies that have driven US healthcare prices and spending to unsustainable limits (although, people have been saying “unsustainable” for about a decade and yet the system is still standing). An argument against telehealth is also an argument against patient access to care, improvements to patient experience, and, potentially, a healthier population.
My Covid-19 experience was enlightening and motivating as we continue to try and move the needle on our outdated and poor-performing healthcare system in the United States. Thinking a little outside the box of brick-and-mortar, listening to patients, working with clinicians to rethink care, and advocating for policy change can go a long way to healing our broken system.
I look forward to being back more often and continuing to discuss technology and policy-driven healthcare innovation.