A New, Better Normal in Health Care? – National Review
The COVID-19 crisis has fast-tracked long-contemplated, patient-centric changes in medicine.
The coronavirus pandemic has challenged health care as much as any industry in America. Across the country, hospitals have confronted the dual burden of preparing for the possibility of being overwhelmed by COVID-19 patients while struggling to maintain financial viability in the face of catastrophic revenue loss as other patients stay away, fearful of exposure to the virus. Meanwhile, physicians, nurses, and other front-line health-care workers have desperately sought to learn and apply the latest information about the virus, only to find themselves picking their way through an unruly mess of strong opinions and weak data.
Yet somehow, out of this maelstrom, several surprisingly consistent themes have emerged, as I learned this week at a large medical-innovation conference convened virtually this week in Boston:
Deferred care — the health services non-COVID patients should be receiving but aren’t — is an increasingly serious problem.
“During March and April, many of our patients with heart disease, with lung disease, with cancer, with diabetes, were simply afraid to come to the hospital, so they didn’t get the care they needed,” said Dr. Elizabeth Nabel, the president of Boston’s Brigham Health, and they are “now returning to the hospital much sicker than if they came previously.” She also noted that the cardiac-catheterization lab — incidentally a key revenue-generator for the hospital — was less than half occupied when normally it would’ve been full.
“We’re very concerned about the cases that we’re not seeing, the decreased number of cardiac and stroke patients showing up in our emergency room” added Dr. Peter Slavin, the president of the Massachusetts General Hospital (MGH). “The fear associated with this virus is very real and is going to take some time to be overcome.”
The use of telehealth has surged.
“Explosive” is how John Fernandez, the head of ambulatory services at the Mass General Brigham (MGB) system, described the growth, and growth prospects, for telehealth and virtual care: “I figure if my 86-year-old father can learn Zoom in a week, there’s going to be a lot of explosion in this technology.” The numbers would seem to bear out his point. At MGH, the use of telemedicine climbed from a baseline of less than 1 percent of outpatient visits to over 85 percent, Slavin said. According to MGB’s chief clinical officer, Dr. Gregg Meyer, the amount of care delivered virtually within the MGB system increased from 2 percent to nearly 60 percent. The actual number of virtual visits increased from 1,000–2,000 per month to 240,000–250,000 per month, said Dr. Alistair Erskine, the chief digital-health officer at Brigham Health — an extraordinary 200-fold change.
It’s prohibitively difficult to gather and aggregate relevant clinical data in a timely fashion.
Dr. Paul Biddinger, who leads emergency preparedness at MGH, highlighted the need to gather “patient presentation data — the emergency-department visits, the clinic visits, the hospitalizations, the ICU visits that tell us whether or not the pace [of reopening] is too fast. . . . Right now, we don’t gather all that data from all those different sources in an aggregate way and link it to the decisions that are being made.”
Marcus Osborne, the vice president of Walmart Health, lamented that, “We [Americans] don’t really have a public-health infrastructure.”
“Public health has been underrepresented in the tech space,” said Dr. Jim Weinstein, the senior vice president for Microsoft Healthcare. “Technology is fantastic, but if we can’t talk to each other, we can’t communicate the appropriate data.”
Biddinger explained to me later that we lack “the ability to ‘flag’ patients associated with disasters [including outbreaks but also no-notice mass-casualty events] in all systems,” and to “define the basic data fields that are ‘always captured’ . . . when the flag is set.” Weinstein agreed, and was especially concerned about the learning opportunities that would be missed because of our basic inability to share data more effectively. He noted that in his previous role at Dartmouth, where he led the large Dartmouth–Hitchcock health system, he was able to cut the mortality rate for sepsis from 55 percent to 10 percent in about three months by enabling better data sharing and communication. He offered a similar prescription for the management of the coronavirus pandemic, arguing that there’s a need to share “data elements we agree on . . . tools that let these data flow.” This seems similar in intent to the COVID-19 Evidence Accelerator, championed by tech-savvy regulators such as Dr. Amy Abernethy, the principle deputy commissioner of the U.S. Food and Drug Administration (FDA).
Big Tech projects restraint.
In contrast to the grandiose arrogance typically associated with tech giants and the irrepressible ideology of digital transformation, the representatives from large tech companies speaking at this conference exhibited deliberate, conspicuous restraint. Physicians from Microsoft and Google constantly emphasized the primacy of patient privacy, and the urgency of ensuring that tech doesn’t exacerbate social inequities.
Dr. Karen DeDalvo, appointed in October 2019 as Google’s chief health officer after serving as a health and technology leader in the Obama administration, emphasized transparency and the need for “privacy-preserving” approaches. To the extent that she even mentioned AI, in a session focused on the topic, it wasn’t in the context of how it’s going to solve all human problems; it was to stress the importance of being “intentional in our development of AI so that we eliminate disparities and don’t aggravate them.”
“I want to be sure that we don’t leave people behind,” Microsoft’s Weinstein said. “We have to be very thoughtful about how we move technology forward in the next generation, and the generation after that, to narrow the gap of disparities, which we still haven’t done.”
Patient-centered medicine at last?
An inescapable takeaway from the conference was the sense that as a result of the COVID-19 crisis, some long-contemplated changes in America health care may have at last arrived. Chief among these is a vision of care authentically built around the life needs of a person, rather than the operational needs of the medical system. As Nabel explained, she and her colleagues recognized that the crisis represented “an opportunity to think bold and think differently, and implement those changes [that] maybe we’ve wanted to do all along but didn’t have the courage to.”
In particular, Nabel emphasized the increased use of digital tools and the re-imagination of the ambulatory-patient experience, changes that would likely lead to less space for ambulatory care in the hospital. “Digital care will expand and be a foundation to all the care that we deliver,” Nabel said. “The transition to consumer-focused health care will accelerate,” which “will mean more choices are available, care will be less hospital-centric, more outpatient/ambulatory, in the home in many ways. We don’t even know what routine care is going to look like in the future.”
Similarly, Walmart’s Osborne highlighted the increased opportunities to provide care and support for patients outside of the traditional medical clinic, whether through at-home kits or the provision of testing and care in more convenient settings. “As communities and individuals and families grasp for healthcare needs,” he said, “they’re not finding public-health infrastructure that exists at any kind of significant scale,” and instead often rely on other organizations to fill the gap. “We’ve done a disservice to consumers by not allowing diagnostic and lab pieces to be up front and more accessible, and COVID has just exposed that.”
A Better Normal?
Talk is cheap. But the emergent vision of health-care’s future is compelling. It’s encouraging to think about a health system that’s more patient-centric — more ready, willing, and able to meet patients where they live, in part by leveraging the convenience and scale of competitive private-sector offerings from both large, established corporations such as Walmart and nascent startups. It’s also a welcome change to feel that tech may be finally be deployed in the service of patients, rather than championed as an end in itself (if only the benighted masses would adopt it). Let’s hope as well that serious tech companies continue to approach health care with the humility and collaborative intent demonstrated this week, and that they forge partnerships with the health-care community that authentically prioritize patient privacy while enabling a permissioned and transparent approach to data-sharing. The rapid learning that would then be possible — chronically stifled by the impediments in place today — is essential not only during an outbreak, but also if we hope to iteratively improve the care our patients routinely receive.
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