Challenges in areas ranging from education to the environment, gender to governance, health to housing don’t exist in a vacuum. Each month, Abt experts from two disciplines explore ideas for tackling these challenges in our monthly podcast, The Intersect. Sign up for monthly e-mail notifications here. Catch up with previous episodes here.
As COVID-19 overburdens hospitals and healthcare workers, health services researcher and clinician Nicole Keane and digital expert Gabriel Krieshok discuss how telehealth can get us through this crisis and beyond.
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Eric Tischler: Abt Associates tackles complex challenges around the world, ranging from improving health and education to assessing the impact of environmental changes. For any given problem, we bring multiple perspectives to the table. We thought it would be enlightening—and maybe even fun—to pair up colleagues from different disciplines so they can share their ideas and perhaps spark new thinking about how we solve these challenges. Today I'm joined by two of those colleagues, Nicole Keane and, making a second appearance on The Intersect, Gabriel Krieshok.
Nicole is a healthcare quality process improvement expert and a registered nurse. Her clients include the Centers for Medicare and Medicaid and the Agency for Healthcare Research and Quality.
Gabriel is a data scientist who manages Abt's diverse portfolio of information and communication technology for development.
Nicole Keane: Hi there.
Gabriel Krieshok: Great to be here.
Eric: Nicole, I'm going to start with you. As we're recording this, we're wading deep in the COVID-19 pandemic and healthcare systems are overwhelmed. One of the challenges is that we need to practice physical distancing to help flatten the pandemic's curve, but that makes it difficult for healthcare workers to treat and diagnose patients. Right?
Nicole: Yes. Thanks, Eric, for having me. It seems like every day we're hearing something different as far as the changing world out there with COVID-19 and how it's affecting clinicians, scientists, regular folks like all of us. What I'm hearing from my colleagues in the field is that, because there's a lack of protective equipment, they're trying to do their best to manage patients as remotely as possible, so we're starting to hear a lot about telehealth and how to use it.
Eric: Right, and that's not something that's typically been widely embraced. That's not a mainstay of health services provision.
Nicole: Well, interestingly, it's been kicking around for many years, but with our healthcare system, a lot of it is about what are you getting reimbursed for? So it's become reimbursed recently, but there's still a lot of requirements that need to be met in order to use it. But, interestingly, what's happening now, CMS has released multiple policy changes on telehealth and we're hearing that things are loosening on those restrictions, and the hope is that clinicians know what those loosening restrictions are and are using telehealth. But we're not quite sure if that's happening completely everywhere.
Eric: Okay. I'm going to get to Gabriel in a second, but first let's talk a bit about what kind of information do we want to be gathering remotely?
Nicole: Yeah, so I come at it as a clinician, so I'm thinking about how does the patient enter the system? And that could be any system. That could be a hospital, that could be a client at a community health center, etc. But they're usually the ones seeking out some sort of care need. The problem with COVID-19 is if you're saying, "Okay, everyone should just be not coming in but contacting us for health," how does the patient learn about that? Does their insurer notify them? Does Medicaid, does Medicare?
So what we're hearing in the field is some systems are pretty quick to come up with a system of letting their patients that usually come to their center know that they should be using anything but coming in person. Maybe it's a telephone, maybe they're on the site's website page, maybe they have an actual portal. But the bit of a barrier is it has to be HIPAA compliant, you have to maintain patient privacy basically, and how do you do that? Can you use a different, non-traditional source? Can you use Facebook? Can you use WhatsApp? So that's sort of all out there right now, being questioned.
Eric: Got you. So it's sort of a two way: One, there's communicating out to patients, and then there's obviously intake. Gabriel, when you hear all this, what are you thinking?
Gabriel: It seems like COVID-19 is really acting as a catalyst to bring to the forefront a lot of these challenges and the intersection of a lot of the challenges related to digital health that we've seen over the years, just not all at once and in so many different areas. So I think, as Nicole mentioned, what is the policy environment landscape like for doctors being able to talk to patients? What are the different platforms that they're able to use? What sort of conversations can you have? How are the records being stored or managed? How do you communicate with the patients in the first place if you don't already have preexisting established modes of communication?
I don't think that anything that we're talking about is really fundamentally new in this space, but I think necessity is the mother of invention. We're just seeing a real earnest effort to really try and understand how we can actually use these platforms. How we can actually adapt to this new reality and adopt digital transformation in the midst of this crisis, and I think you're seeing some really significant challenges but also some really interesting opportunities are being created out of it as well.
Eric: So can you talk to the opportunities? Given what Nicole just said, what are some ideas that leap out to you about how to establish these secure connections?
Gabriel: I think a real good example, to build off of what Nicole mentioned around privacy, is the loosening—and that might not be the best word, so I'll defer to Nicole on how to articulate the HIPAA regulations and what happened, what is happening there. But I think just being able to acknowledge that doctors can talk to their patients now sometimes across state lines, or there's something about being able to practice over across state lines and then being able to use different modes of communication to talk with them either through the phone, through email, through Zoom conferencing, tele-video services and things like that. Obviously those are some of the more obvious places.
And then when you start to think about end-to-end encryption and data security and privacy, you're starting to see services that explicitly pop up, or even just that those issues are being addressed at a high level. You're seeing a lot of conversation and dialogue around, what is this particular platform, what are they doing with their data? A lot more attention is being put onto these services to ensure that the data surveillance and capture isn't being used for wayward purposes, or at least people are being informed about what's actually happening to the data they're putting into these platforms.
Eric: Okay. So Nicole, what telehealth solutions are in play and what do we know about those challenges specifically that maybe those practitioners are facing?
Nicole: That's really interesting, Eric. I do a lot of quality improvement work, so we have these group discussions with multiple health systems. We just had one yesterday for a federal project on opioids and we wanted to hear what are the barriers, what's happening? So we heard firsthand, one site has gone to all telehealth. They've shut down some of their physical sites and they've just completely moved to a telephone-based system where they're having medical assistants set up the appointment and then the clinician hops on to do what they need to do. CMS has already released ICD 10 codes and other types of codes so that folks can get reimbursed. Obviously that's not the biggest need, but no margin, no mission.
And then also I am hearing clinicians are doing their best to document explicitly why they're doing what they're doing, such as “patient seen due to no ability for in-person visit due to COVID-19.” The other thing I've heard someone's using some technology called Doxy. Now, I don't know if that's a regular telemedicine program that's now just allowing their product to be used for free, but that one system was using Doxy. And then I've heard some systems just have frozen and they're still in the midst of putting together an operations-based solution. So I think it's all over the place as far as how well systems are managing the patients that need to be seen for everything, not just potential COVID-19 rollout.
Eric: Right. Is there a lowest common denominator for people who maybe don't have a lot of access to technology?
Gabriel: In terms of what your floor is, I guess in terms of your lowest common denominator of access, I work a lot on international projects so, while we might have some very sophisticated, amazing web platform that works quite well in the U.S., maybe that only works well if you have high-speed bandwidth, low latency, which means that the connection from my computer to the computer that I'm connecting with—to that server or that service—is very quick. So I'm not waiting for a lot of response times, things like that. We often take that for granted in places like the U.S., but you go to many other places in the world and you struggle to find a 3G data connection on your cell phone. You struggle to find wi-fi, to say nothing of high-speed broadband, always-on internet access.
And so what you've seen a lot of over the years has been a lot of really interesting innovation around offline-first platforms and approaches that assume that everyone is going to be offline, that your phone, as that lowest common denominator, has to be able to get the relevant information on it, and if it gets access to a server or a data connection, that it's able to use that bandwidth efficiently to be able to not require the full bandwidth to be able to get data services from it and to ramp up step-by-step as you get access to better services. One great thing about that set up is that that's been ported over to places in the U.S., and so you'll hear a lot about offline first or progressive web apps, which are cutting edge technologies that rely on similar principles that were developed in a lot of ways for purposes in the Global South and in the developing world.
So we're seeing a lot of advances like that, and I think you see some similar approaches here. Thinking through what is the worst-case scenario, that offline-first scenario, that “Do we have SMS connectivity? Check.” How are we approaching that? Do we have a voicemail system? Do we have IVR, interactive voice response? That allows you to go through nested phone listings, phone tree situations just from your phone touch pad. These are technologies that have been around a long time and for good reason. They're reliable, we've tested them in a lot of different ways and languages, and they work. So a lot of good stuff there. I think building up from those technologies is a good place to start.
Eric: Let me ask real quick about it right there, for people who don't even know to ask these questions, maybe—and Nicole, I don't know if you feel like these are questions people are already asking. It sounds like there's a wide range of people with a wide range of knowledge. Where might people look for those kinds of solutions? What's your first step if you need to build something from the ground up to find those answers?
Nicole: Let me just hop in here and respond to Gabriel, because I've been thinking about this a lot. In our very high-tech world things have changed and I'm thinking about when I practiced as a clinician 20 years ago, how much things have changed. We didn't have iPhones back then, so it was very much old fashioned, using telephones, paper, which creates all sorts of problems. But I think the floor really is—the base that you need to have—is a telephone because folks are using their clinical skills to be able to assess folks through questions. Very basic questions can get you moved from, "Okay, you need to get a test and here's the order for it," or, "No, I think you can stay at home and call us back in 48 hours." I think nowadays, if we could at least have that, all of the clinicians have a basic smartphone during this time, I think that would help a lot to go with triaging and managing things remotely.
Gabriel: I'm nodding emphatically over here. That's a really good point. I agree completely, and I think that's the right thing.
Eric: So everyone's got a cell phone, or everyone's got a smartphone, rather. That's a baseline. So then back to what you were saying, Gabriel, what's a way that people can start to look at this holistically? I've got my smartphone, I need to connect with my patients or potential patients. What's my next move?
Gabriel: Part of these, you have to bucket them off into, is this a technology question? Is this a privacy question? Is this a compliance question? I do know that the privacy and security piece is a big piece of it. It's being discussed on all sides, not just from the clinical side, but from the consumer health side, from the political side, the governmental landscape, regulatory environment. What are the safeguards that people need to put in place?
Eric: So that gets to another question I wanted to ask, and I'll ask you, Nicole. Would it be helpful to have an exercise where people crosswalk what are the privacy needs, the legal needs, and the data gathering needs to figure out what solutions are really going to work, and pretty long term, like what you've both been saying. Coming out of this, hopefully we have some more robust solutions in place for the future. So is that an exercise worth pursuing, Nicole?
Nicole: So I'll answer that two fold. First off, what I'm hearing is clinicians are just giving patient care. That's coming first. They're not worrying about anything else. They're just doing it and let the chips fall where they may after everything hopefully cools down quickly. But secondly, the genie's out of the bottle. Telehealth will be used because this will go on for longer than probably the short term. Will clinicians go back and say, "Okay, I was able to use that one time, but you're not going to let me use that now.” Especially when it was very effective. More patients could be seen. Perhaps they could be seen quicker. So moving forward, that crosswalk that you speak of, Eric, would be necessary, I hope, to justify that telehealth will be used more often after the pandemic.
Eric: And it sounds like we’ll need that subject matter expertise in health and data and digital … and that's why we call this podcast The Intersect. Thank you both for joining me.
Gabriel: Thank you.
Nicole: Thanks, Eric.
Eric: And thank you for joining us at The Intersect. In the spirit of social distancing Nicole and Gabriel called in to engineer John, who recorded them safely from his home studio. I hope you're staying safe, too.