Telemedicine is an intervention that facilitates patient access to healthcare outside of the doctor’s office. To manage overwhelming patient populations, in recent years, hospital systems around the world have started to embrace it. The arrival of the COVID-19 pandemic has only accentuated the value of this approach with mandatory measures like lockdown and social distancing in place. “The interest in remote or virtual care delivery has been accelerating in the last five years, but our time to shine is now,” says Dr. Joseph Kvedar, who has been a staunch advocate of digital health for close to three decades. A seasoned dermatologist at Harvard Medical School, Dr. Kvedar has been at the forefront of telemedicine with his eminent leadership at Partners HealthCare. We invited him for a discussion on the promise of the field.
Looking back, one reckons virtual care has always been a practical option for those who value convenience. In the past, house calls were quite prevalent, and patients received care in the comfort of their homes. Even during the age of urgent care clinics and multi-facility hospitals, it was not uncommon to consult with physicians by phone. Present-day advances in telecommunications technology, remote monitoring capabilities, and archiving have provided us the infrastructure to restore this trend. However, virtual care is still in the early stages of gaining widespread acceptance. We interviewed Dr. Joseph Kvedar, a pioneer of the telemedicine field, to precisely understand the reason behind.
Barriers to Telemedicine Adoption – The Early Days
Dr. Kvedar launched the Partners HealthCare Center for Connected Health in 1995. Partners HealthCare is an integrated health system founded by Brigham and Women’s Hospital and Massachusetts General Hospital and is a principal teaching affiliate of Harvard Medical School. The progress of telemedicine itself has influenced the evolution of his institution’s mission. Therefore, we commenced the interview by asking about the hurdles in the field.
In the early 1990s, he had the chance to look at the utility of digital imaging in dermatological diagnosis. “At the time, I had an epiphany that the doctor and the patient need not be in the same room at the same time. I thought healthcare was behind, but in retrospect, I was a bit ahead of the market”.
He further went on to describe the specific challenges that the Center for Connected Health had to overcome at different stages. “In the first decade, we had to prove our concepts because of a very skeptical provider audience. We performed research with outcomes data to demonstrate that connected health tools could deliver high-quality care.” He recounts that Partners was among the first pioneers to use video conferencing and early website technology to monitor people at home. So, in addition to the skepticism, they also had to deal with a rudimentary technology that was expensive.
He defined the second era as the phase when things started to naturalize and the technology became less expensive. The internet made features like Bluetooth and Wi-Fi more easily accessible, and the computer went from a desktop to a handheld device. Gradually, healthcare providers started to signal their acceptance, as long as they had data to show its increased efficiencies and an understanding of how to combine it with their clinical workflow. Also during this decade, Partners began integrating these connected health technologies into its population health vision, to serve a large cohort of patients with chronic illnesses.
Current Challenges – The Third Era
Dr. Kvedar notes that numerous challenges still hamper the progress of telehealth. Practitioners in a one-to-one care delivery model struggle with issues such as choice of software, integration into electronic health records, and billing payers. He admits that technologies must be simple to implement and use, much like we see in other industries that are using technology to enhance the consumer experience, such as Amazon or Uber.
He opines that, although not one-hundred percent, patients, in general, are quite eager to adopt technology that’s easy and convenient. “On the consumer side, the lack of familiarity is a barrier. One of the things we have learned from experience is that patients value access to convenient and high-quality care in their homes. Healthcare delivery has a lot of friction points and these kinds of tools help to better engage patients and providers, and keep individuals on track with their personal health and wellness. The current challenge is to implement telehealth at the national level.”
The Role of Payers
The health insurance payer is a critical stakeholder in the healthcare ecosystem. In the US, there are three primary types; 1) Public insurance including Medicare, Medicaid, and other government programs, 2) Private insurance, and 3) Commercial payers. So, when asked about their acceptance of telehealth, Dr. Kvedar says that payers were initially very reluctant.
He explains that the relationship between employers and employees creates an interesting marketplace. Historically, employers would unveil benefits packages inclusive of health plans offering telehealth. However, third-party providers set up shadow systems to control the spending limit and thereby lowering the quality of care. He expects that in the future, health plans will expand their telehealth offerings. “They are going to learn that people don’t overuse services. It just hasn’t happened yet.”
Wearable Devices and Chronic Disease Prevention
We then steered the conversation to the collection of health data for disease prevention. Dr. Kvedar agrees that interventions such as wearable devices have been fascinating and explained the two kinds of technologies that existed ten years ago. One was the medical-grade tools, which were relatively expensive and used for monitoring illness at home. The other were fitness trackers, which catered to the motivated health enthusiast. He is excited to witness these two extremes merge into a wide range of devices, including smartphones, watches and other wearable tools, that provide individuals the opportunity to better manage their health, from simple medication reminders to monitoring vital signs, for conditions such as hypertension and diabetes.
He says the future is bright with the arrival of more technologies. For instance, a company called Proteus has an ingestible sensor, and wearable technologies can measure everything from respiratory rates to stress levels. “All these interventions are useful in the right context,” he said. However, obtaining real-time data is vital. He compares this to how executives at Fortune 500 companies can look at a dashboard with all of the relevant market information they need, in real-time, to run their businesses. “Perhaps in the future, we will have the market forces to do that in healthcare too. It’s up to us to separate the chaff and present the wheat to our providers”.
Telemedicine and Mental Health
In his opinion, telemedicine is an important tool for addressing behavioral health, which allowing for real-time interaction with a patient in their home environment. Not surprisingly, the adoption of telemedicine has been the highest in this area, at 48 percent. A telehealth visit can be less stressful for a patient, and offer valuable insights to the provider about the individual’s home environment that could influence behavior. There are a number of telehealth solutions that offer cognitive behavioral therapy to patients through chatbots and mobile apps, as a way to extend health care across more patients. “There are lots of innovations in telemedicine concerning mental health, and there are more to come,” he added.
Data Privacy during Emergency Situations
Dr. Kvedar opined that, because of the ongoing coronavirus pandemic, regulators have temporarily waived certain restrictions and barriers to telemedicine. “The urgent need to quickly and safely provide care during this health crisis has resulted in the easing of certain barriers to allow greater access to telehealth services across the country”.
However, data privacy remains an important topic. Title II of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) encompasses the privacy guidelines to ensure the confidentiality of health information and to protect the identity of patients. In late March, the Department of Health and Human Services announced certain provision waivers to the HIPAA Privacy Rule in light of the COVID-19 emergency. As a result, not all technologies being employed in response to this crisis may not fully comply with HIPAA requirements.
With extensive data stored on cloud platforms, Dr. Kvedar admits that privacy breaches are a risk, but affirms that healthcare providers take this very seriously. Apart from the doctor-patient privilege, there is a legal obligation in the US to keep patient information private, and providers have a moral responsibility to protect personal health data. He explained that all the technology platforms they use are very secure, especially the electronic health record (EHR) providers.
“We, as healthcare providers, care deeply about privacy. At our workplace, we use Epic, a cloud-based EHR solution and we have integration with a company called InTouch Health. So, we provide an exceptionally secure video call through our patient portal. During this pandemic, the government has also recommended the use of publicly available platforms such as Skype and FaceTime, which also offer end-to-end encryption”.
Whole Genome Data and Personalized Medicine
Dr. Kvedar says he has been interested in the endeavor of using whole-genome data for personalized medicine for almost 15 years now. In addition to tracking one’s physical location, there is a wealth of information on an individual’s mobile device. “We have seen correlations between the volumes of outbound messages on the phone with a person’s mental health status. That information can be put into artificial intelligence algorithms to screen for depression”. He shares the example of Sweetch, a digital health start-up from Israel, that is tracking information from patients with chronic illnesses and presenting them with a highly customized set of messages and tools to improve health.
However, he acknowledges that his expectations aren’t fully realized yet. “We tried to apply it with a couple of pilots and were not quite successful.” He feels that the integration of phenotypic and genotypic maps is incredibly powerful in assessing health risks and it allows them to customize programs that are uniquely suited to individuals. “There are four or five genotypes that predict obesity, for instance, and one of them was lower metabolism at birth. So, if we knew that information, we could put a person under motivational activity programs early in life. Right now, I think we haven’t even scratched the surface”.
Dr. Kvedar says that in the past century, we have added 25 years to our lifespan with healthier lifestyles, medications, and an improved understanding of diseases. But, we haven’t focused enough on helping older adults remain productive, engaged and independent. At the age of 65, most people in our society are considered of retirement age, and their perceived value is diminished. His new book, ‘The New Mobile Age: How Technology Will Extend the Healthspan and Optimize the Lifespan,’ is about using technology to improve healthcare delivery to that cohort. “The idea is to make sure those extra years are productive, healthy, and enjoyable.”
He has undertaken some exciting assignments recently. He is the president-elect of the American Telemedicine Association (ATA) and also the Editor-in-Chief of npj Digital Medicine. Besides, he is the co-chair of the American Medical Association’s Digital Medicine Payment Advisory Group. Also, he works with the Association of American Medical Colleges on integrating telehealth training into the curriculum of medical students. He describes all four of these roles as fulfilling, fun projects with an opportunity to make a difference at the national level.
In conclusion, we asked him about his future goals. As an Editor in Chief, he aims to get the journal to a higher level of consciousness for non-scientists. “The previous team did an enormous job of launching the journal and inviting high-quality manuscripts. I’d like to the journal include conversations with policymakers, entrepreneurs, and business executives. Digital health is becoming part of health, and we want to be the premier place that thinks about that integration”. His vision for the ATA is to shepherd the trend towards the broader adoption of telemedicine. It involves multiple constituencies and stakeholders such as healthcare providers, patients, and tech suppliers. “We want to make sure that all of these people have a common purpose. We can advocate and do things together by sharing best practices,” he concluded.
Interviewer: Rajaneesh K. Gopinath
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