Utilizing AI and Wearable Technology to Democratize Access to Physical Therapy in Underserved Populations through Tele-Rehabilitation

When it comes to rehabilitation services, distance and cost should not be barriers to care. Tele-rehabilitation uses technology to bridge these gaps, delivering vital rehab to those who need it most. With over 2 billion people worldwide living with disabilities, innovative solutions are essential. The research shows tele-rehab works, improving key outcomes like mobility and strength when compared to in-clinic care. And it does this at a lower cost to patients and healthcare systems. By combining tech tools like wearable sensors and artificial intelligence (AI), tele-rehab has huge potential to transform rehab delivery across the globe. It can bring specialized, effective care right to people’s homes, no matter where they live. This approach promotes health equity and can help meet the massive unmet need for rehabilitation.

Wearable technology and artificial intelligence are key catalysts that can help telerehabilitation live up to its potential for transforming rehabilitative care.

Wearable sensors like activity trackers and motion sensors provide real-time monitoring of patient movement and progress when integrated into tele-rehab programs. A recent study on telerehabilitation for elbow fractures used motion trackers and biofeedback devices to monitor joint mobility and provide visual feedback during remote therapy sessions, resulting in an improved range of motion.

The continuous stream of patient data from wearables enables the use of artificial intelligence and data analytics to personalize telerehabilitation in real-time. AI algorithms can analyze wearable data to track patient progress, adapt exercise difficulty, and provide feedback based on each patient’s capability and needs. For instance, a study on AI-assisted telerehabilitation systems for stroke survivors employed machine learning (ML) to analyze patient movement and automatically adjust the exercise difficulty to match their motor capabilities, thus enabling a more personalized rehabilitation experience.

Tele-rehabilitation, powered by wearables and AI, breaks down barriers to care, delivering personalized, cost-effective rehab and advancing public health goals.

By combining wearable technology and AI, telerehabilitation can deliver individualized therapy remotely while giving therapists crucial insights. This was highlighted as part of the AFTER (App-Facilitated Tele-Rehabilitation) program for COVID-19 survivors. Paolo Bonato, Ph.D., an Associate Faculty member at the Wyss Institute, underscored the significance of wearable technology in rehabilitation, stating that it is “suitable to accurately track motor recovery of individuals with brain injuries and thus allow clinicians to choose more effective interventions and to improve outcomes”. This assertion emphasizes the pivotal role of wearable technology, coupled with AI, plays in refining telerehabilitation strategies, making it a more precise and impactful approach to patient care.

Together, wearables and AI make telerehabilitation scalable and responsive to each patient’s progress. With further research, they can enable tele-rehab to fulfill its potential in transforming rehabilitation delivery.

How can telerehabilitation help us achieve public health goals?

Tele-rehabilitation helps to advance public health goals in rural and medically underserved areas by improving access to rehabilitation services. Research has shown that telerehabilitation interventions can successfully overcome geographical barriers to provide rural patients with essential rehabilitation care. One such study is published in the Journal of Telemedicine and Telecare emphasizes that reducing healthcare inequities is a major public health goal that is directly aided by this increased accessibility.

Telerehabilitation has also been demonstrated to improve patient participation and adherence to treatment. Another comprehensive analysis suggests that telerehabilitation interventions consistently result in higher adherence rates than traditional in-person rehabilitation. In medically underserved areas, this is essential to obtaining improved health outcomes.

The average daily rehabilitation expenses per individual amounted to approximately $1,600, resulting in a total cost of around $46,000 per person. Another significant benefit of telerehabilitation is its low cost. There have been research studies which identified substantial per-person cost differences, ranging from $565.66 to $2,352 in savings. Tele-rehabilitation helps patients and optimizes resource allocation in healthcare systems by eliminating the need for lengthy travel and simplifying the delivery of care. Platforms for telerehabilitation frequently include data gathering and analysis, allowing for the creation of individualized care plans and evaluation of results. A recent study in the Journal of Telemedicine and e-Health, tele-rehabilitation highlighted the need for data-driven decision-making, which helps rural healthcare providers tailor their offerings to the unique requirements of their patient communities.

Furthermore, wearables and remote patient monitoring (RPM) tools are examples of cutting-edge technology solutions that support telerehabilitation. These developments give rehabilitation specialists additional ways to track patients’ progress and deliver timely treatments.

To summarize, telerehabilitation has a substantial impact on meeting public health objectives in underserved areas. Research continuously demonstrates how well it works to increase patient involvement, ensure cost-effectiveness, and improve access to care. In addition, it makes data-driven decision-making easier and makes use of cutting-edge technologies to offer complete rehabilitation services. To fully utilize telerehabilitation in addressing public health inequities in underprivileged communities, further research and policy assistance are required.

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The healthcare industry has undergone a profound transformation, driven by technological advancements and changing patient needs. One of the most significant shifts has been the widespread adoption of telehealth services fueled by the COVID-19 Public Health Emergency (PHE). It took just a little over three years since the start of the PHE for most healthcare providers to report that they are comfortable, if not proficient, with telehealth. What does it really mean to be proficient with telehealth? What are the competencies required to claim proficiency? In March 2021, the Association of American Medical Colleges (AAMC) published “Telehealth Competencies Across the Learning Continuum” as part of their New and Emerging Areas in Medicine Series. They intended these competencies to help educators design and deliver curricula and related activities and help learners in their individual professional development in telehealth. They explicitly state that the competencies are not intended to be used for high-stakes assessments or accreditation of schools, programs, or institutions. I would beg to differ.

In this digital age, where technology continues to redefine our daily lives, healthcare professions training programs cannot afford to lag behind. Telehealth competency has emerged as a critical skill set for healthcare professionals, but it is far more than a checkbox on a resume, taking a class, or acquiring a set of technical skills. The AAMC was spot on in saying that telehealth competencies go across the learning continuum. However, these competencies should not be seen as “nice to haves”, but as imperatives. Without high-stakes assessments or impact on accreditation, it could take years or even decades before this happens. These competencies need to be woven into the very fabric of every aspect of health professions education with a sense of urgency….and even that is insufficient.

Telehealth competency necessitates adopting a transformative mindset, transcending the notion of a mere class or sequence of courses.

Historically, health professions education has been built on the foundation of the in-person model of care. Therefore, telehealth has been viewed as a mechanism for extending access to care in situations where in-person care is not feasible and/or as a more convenient alternative to in-person care. Telehealth competence is, therefore, defined as the ability to successfully replicate in-person services in a virtual setting. Admittedly, this is no small feat. It requires technical proficiency, an understanding of legal and ethical considerations, the ability to communicate clearly and compassionately through technology, the capacity to ensure data privacy and security, the skills to assure equity in access for patients from diverse cultures and needs and more. These are critically important competencies that many providers have yet to master. But I want to make the case that these are starting points for telehealth competency, and not end goals. 

There is significantly more that can be done with digital health tools that augment in-person care, and for which there is no in-person equivalent. For example, telehealth also brings the opportunity to monitor patients remotely, gather data with the aid of artificial intelligence (AI) for better decision-making, and provide timely interventions—all of which can lead to better health outcomes—transitioning from the status quo in-person care model to a hybrid model that fully embraces all available telehealth and digital health tools is needed for the future of modern healthcare. 

We all need to take a step back and rethink how we educate, practice, and experience healthcare. What better place to start than with health professions education? Telehealth competency necessitates adopting a transformative mindset, transcending the notion of a mere class or sequence of courses. If we work backward, a transformative mindset in health professions education is one that produces health professionals who enter the workforce:

• Knowing the value of telehealth and how technology can be used to improve access to care, enhance patient experience, and lead to better health outcomes.
• Having a good understanding and proficiency in navigating technology, legal and ethical considerations, telehealth etiquette, and telehealth equity.
• Feeling empowered to make sound clinical decisions about what digital tools to use, when and with whom to use them, and how to assess whether these tools add value. 
• Able to quickly adapt and pivot as new tools emerge; proactively integrating new technologies and methods into practice as appropriate.

How might we change the way we educate providers to achieve these objectives? This process will require a combination of intentional design and imagination, and it must start now. We need to look carefully at the structure of existing curricula, the sequencing of courses, the teaching methods and experiences, the assessment and evaluation tools, as well as the accreditation requirements. We also need to look closely at faculty professional development. Having the next generation of health professionals equipped not only with technical skills; but also, with the ability to provide patient-centered care, navigate legal and ethical complexities, embrace technology and innovation, and adapt to an ever-changing healthcare landscape is imperative for ensuring that these professionals are not just ready for the future; but able to shape it.

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The University of Kansas Health System, along with the University of Kansas, has been a pioneer in telemedicine for more than thirty years. In the months leading up to the pandemic, it was typical for our providers to see around 100 patients per month. We specialized in telestroke, telebehavioral health and telecancer throughout the state of Kansas. The laws at the time limited our providers and patients to being physically in a clinic space in order to give and receive telehealth care. Like most health organizations, the pandemic accelerated the demand for telehealth. At the height of the pandemic, our providers gave care to more than 1,200 patients daily. Today, our telehealth volume has leveled off to 600 patients a day. To meet the initial demand, 2500 plus employees pivoted from their regular duties to help with the implementation of software, hardware, testing and education in order to bring providers, support staff and patients up to speed on the new technologies.

A few months into the pandemic, we expanded our telehealth capabilities by offering virtual urgent care, grew our asynchronous care offerings and created a remote patient monitoring (RPM) department. Our digital care interactions with patients totaled more than 1.7 million last year alone. Within the last three years, we have witnessed a paradigm shift in which more and more of our patients have come to expect a menu of offerings to receive their care beyond in-person and many of them want to do so in the comfort of their home. We calculated last year alone, we collectively saved our patients 2.5 million miles of driving, countless hours of time off from work, extra childcare, hotel expenses etc. Additionally, we noticed a positive impact on missed appointments. A challenge, of course, is balancing patients’ expectations of wanting to do many things digitally. One example is reconciling with physicians accustomed to seeing the first patient encounters in person…not via telehealth. While our numbers speak of great success, it has been challenging helping patients understand why, some care necessitates they come in and encouraging providers to offer virtual care. Initially, to promote telehealth and build confidence among providers, our telehealth department went on a sort of roadshow to all our departments touting the benefits of telehealth, i.e., fewer canceled appointments, ability to deliver care sooner, increased patient satisfaction, etc. We learned; however, this approach did not yield the success we were hoping to achieve by increasing the number of specialties offering telehealth. Word of mouth by champion providers was ultimately the key to showcasing the power of telehealth. As they promoted the benefits of telehealth to their colleagues, our email inboxes filled up and phones started ringing. Today, our team continues to partner alongside more and more specialties to develop workflows designed to free up in-person appointments for higher acuity patient appointments and safely move more patients to our virtual options. Another benefit of telehealth has been building relationships throughout Kansas and Missouri by allowing patients to stay hospitalized in their community while having access to our specialized care as needed.

Telehealth helps close the access gaps to all patients, no matter where they live.

Something worth noting is how the temporary relaxing of several federal and state laws along with private payor policies helped break down barriers to telehealth which limited telehealth to certain providers within a certain geography in order for providers to be reimbursed. While these geographic restrictions were designed to give patients access to hard-to-reach services in rural areas in our country, patients in very urban settings also can experience situations which limit their ability to see a provider. Telehealth helps close the access gaps to all patients, no matter where they live. As we move forward, we are continuing to work with federal and state lawmakers to encourage codifying some of the temporary relaxation of laws into permanency including the important extensions within the Consolidated Appropriations Act of 2023 and CMS’s physician fee schedule. Just as important are the parity laws in which states hold the power to mandate. Hospitals which offer telehealth as a part of their care options do not have the cost savings as standalone telehealth companies. Hospital-based telehealth programs still have the overhead costs in order to provide both in-person and telehealth care. The concerns are providers will eventually become frustrated with the lower reimbursement and change back to more in-person, higher reimbursable encounters. From a policy standpoint, there is a need for caution to consider this when changing and applying reimbursement policies unilaterally to all telehealth care. It has been encouraging to see how our involvement in writing several bills and policies has been presented for debate at the federal and state levels, as well as policy changes with our private payors. As the Public Health Emergency (PHE) for COVID-19 continues to be further behind us and other issues work their way to the top of our policymakers list, the temporary gains accomplished in expanding telehealth are meeting some headwinds.

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The past few years have been a constant roller coaster for those in Telehealth. There have been significant changes in the regulatory environment, the corporate makeup of the industry, provider interest, and consumer preferences. We are finally settling to a new normal, bringing stability and predictability to supply and demand. Many organizations in response are evaluating strategies around digital access and telehealth. Developing project plans to meet consumer demand through improving access and convenience with telehealth.

Telehealth saw a significant increase in adoption due to the COVID-19 pandemic. Patients and healthcare providers turned to virtual visits to maintain access to care while minimizing in-person interactions. This has since been followed by a slow cooling-off phase. Most programs have settled into their new normal for telehealth. We are now in the baseline period for most organizational telehealth strategy work.

Most states relaxed regulations around telemedicine to make it more accessible during the pandemic. The federal government has yet to solidify telehealth coverage to the home for medicare patients. The coverage is extended until December 31, 2024. Not having it be a permanent benefit without expiration is a significant risk for organizations seeking to invest further in telehealth. If you are following the recent DEA comment period on the registration allowance for the Ryan Haight Act, it appears the regulation makers are not congruent with common expectations in the healthcare market. Despite such great progress in our regulatory landscape, much more work is needed.

Telehealth has seen plenty of vendor mergers and acquisition activity, coalescing a few giants.  There are numerous VC-funded startups, all seeking to become unicorns. New entrants to the telehealth provider space by international corporations with household names has caused quite a stir in the industry. We have seen a lot of failed and discontinued services, along with very successful and proven models of care adopted nationally. I have no prediction around the corporate makeup of our industry except to state it will continually evolve and change. New entrants and existing provider groups rethinking strategy and product offerings is the largest opportunity for vendors in telehealth. Expanding the focus beyond telehealth to digital strategy is ideal. Addressing digital front door, patient engagement tools, and whether to develop apps are large projects that need to have a cohesive strategy.

Organizations should focus their strategy on including digital access, future possibilities with AI, and continued focus on physician and patient buy-in.

With the new normal, organizations and telehealth departments are focusing back on provider satisfaction and patient experience. Before COVID-19, I considered my job as leading a grassroots movement to virtual care. We are back to that mindset. Convincing providers of the utility and benefits of telehealth. Supporting well with intuitive tools that work without error. Designing systems to support clinical workflows matching in-person care.

Those developing strategies in telehealth are well advised to in tandem develop strategies around Artificial Intelligence (AI). When I began working in telehealth eight years ago, the hot feature I would hear during sales calls was how they were market disrupters. Though the term is still around, it is not as valued in purchasing decisions now. AI is now the favorite term in telehealth marketing and is on the agenda of every major conference. Some front runners and innovative workflows are making waves in the industry. Most organizations are either investigating or outright developing AI strategies. There are very loud voices sharing concerns around AI in healthcare. I have heard issues around data security, diversity and equity, and even ethical dilemmas in decision-making processes. A notable concern raised is AI models with repeated input of information produces some variation in their output. Inconsistency is not how healthcare decision-making should happen. Regardless of the concerns, AI has a lot of promise and opportunity. In my opinion, the most significant opportunity lies in leveraging methods to decrease provider time documenting in the electronic medical record (EMR). The great resignation of COVID-19 resulted in shortage of resources to manage the demand. Provider burnout is a crucial problem in our industry and AI can significantly help.

The next phase of Telehealth healthcare will be the Telehealth strategy in the new normal.  Organizations should focus their strategy on including digital access, future possibilities with AI, and continued focus on physician and patient buy-in. The federal government must solidify reimbursement coverage to the home and also the provider type expansion that is currently extended to the end of 2024. It will be critical for some organizations to determine where to make future capital investments.

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As leaders in the healthcare industry, providing high-quality care to our patients remains at the forefront of our missions. We strive to keep people healthy, to end needless suffering, and to treat illness. Equally as important is the experience of our clinicians and our patients, enhancing interactions through rapport building, active listening, and shared decision-making incorporated into each encounter.

Today’s world is filled with technology – it’s how we communicate in so many ways. So the question becomes – does every interaction between doctor and patient need to happen in person, in an office? Does there need to be an in-person requirement to ask a patient how they are feeling? To look them in the eyes? To listen to them? To write a prescription? The answer to this question is no, not always. But we do need to assure that the human connection is not lost when interactions are not occurring face to face.

In the United States, physicians are trained on seven core communication competencies:

(1) building the doctor-patient relationship;

(2) opening the discussion;

(3) gathering information;

(4) understanding the patient’s perspective;

(5) sharing information;

(6) reaching agreement on problems and plans; and

(7) providing closure.

We need to ensure that these core competencies are not lost. Instead, they are effectively translated to whatever modality we use to interact with patients, be it in person, through SMS, asynchronous video recordings, or remote monitoring. This will require training of clinicians and non-clinicians alike, and education in our medical schools and residency programs. We also need to acknowledge that with this new world of interaction and information collection through digital data, we must be stewards of patient privacy and security.

Take this opportunity to document and memorialize workflows and processes in your organization – leverage the progress and momentum that occurred during the COVID pandemic.

The COVID-19 pandemic accelerated a growing trend in the usage of telehealth. Seemingly overnight, telemedicine visits spiked across the nation as providers scrambled to find new methods of providing care amid the pandemic. Many organizations witnessed change spurred at unprecedented rates as healthcare staff was forced to change workflows and processes ingrained in daily operations. Years of care delivery advancements took place in only a few short months to meet our patients’ clinical, safety, and access needs. As medical offices and clinics postponed or dramatically reduced care across the country, those that adopted telehealth provided an opportunity to continue care while mitigating physical – and psychological – challenges resulting from the pandemic. 

Some do not realize that the definition of telehealth goes far beyond synchronous video or telephone visits, i.e., telemedicine, which is only the tip of the iceberg. Telehealth, or virtual care, is a broad term encompassing a wide spectrum of digital capabilities, including remote physiologic and therapeutic monitoring, e-consultations, digital check-ins, and digital therapeutics, to name a few. These options should be seen as tools that augment the care of patients – not as care alternatives or replacements for traditional care delivery. If there was any silver lining to the pandemic, it was that virtual visits should now be considered a core component of longitudinal care delivery – a routine way in which clinicians interact with their patients.

Take prenatal care, for example. The American College of Obstetrics and Gynecology supports a hybrid care model for prenatal care, where certain visits can be conducted virtually in an effort to “enhance, not replace, the current standard of care”. This reduced the burden of the traditional 11-15 in-person prenatal visits, improved efficiencies by consolidating procedure-based care in-person, and left time for education, providing guidance, and shared decision-making through a virtual visit from the comfort of a patient’s home. The addition of blood pressure and glucose remote physiologic monitoring for high-risk patients could serve as a key quality enhancement to routine prenatal care.

Implementation of hybrid models of care or the addition of new services, including remote patient monitoring, will require change management. There will be different workflows, care teams, clinicians’ expectations, reimbursement structures, and technology requirements. Clinical documentation in EHRs are typically set up for patient encounters and not asynchronous interactions. Data will need to be stored and trended, alerting a clinician only when clinically appropriate. There will be an opportunity for higher engagement with patients. Still, the role of the physician and other care team members, the frequency of digital interactions, video interactions, and in-person care will need to be better defined. We should advocate for new funding opportunities and grants to test out hybrid care programs, allowing all healthcare systems – regardless of size and resources – to take the leap into hybrid care, test, iterate, and learn. 

It’s pivotal to ensure virtual care results in equitable access and does not further the digital divide. Meeting people where they are is perhaps one of the biggest benefits provided via virtual care. A 2018 Cedars Sinai study showed that a pharmacist-led, barbershop-based medical intervention could successfully lower blood pressure in high-risk African-American men. Coupled with synchronous or asynchronous physician visits, such programs have significant potential to reach underserved communities. Programs can be simple – a connected tablet in a homeless shelter or a virtual visit “office” in a public library can allow for equitable access and support the bridging of health disparities.

As healthcare leaders in the post-COVID era, we have a great opportunity to advance the adoption of virtual care across all facets of healthcare. Take this opportunity to document and memorialize workflows and processes in your organization – leverage the progress and momentum that occurred during the COVID pandemic. Explore new opportunities for telemedicine and digital health, including emerging fields such as remote patient monitoring.  And, on a more global basis, monitor policy developments and advocate to support ongoing access to virtual care. Together, we can ensure virtual care becomes a key component of providing high-quality care to the patients we serve, wherever they are.

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Few, if any, of our cohorts in healthcare IT could have foreseen the unveiling of a global outbreak in the early days of 2020. And while my health system had dabbled in telemedicine for well over a decade, we were woefully unprepared, as were many, when the first wave slapped our doors shut. By the second month into the public health emergency, our volume had increased by 2000% over pre-COVID days. We had moved the needle by years in a matter of months, even weeks.

Telehealth proved its value during the pandemic out of necessity. And now, we must not let it lose its luster.

The pandemic offered little hope to humanity, save one thing. The hope of innovation, out of necessity and desperation, in the form of a digital paradigm shift in healthcare. Seemingly overnight, all of the fears and skepticism of this emerging care model were swept away, and telehealth was embraced by the masses. Out of the most challenging and heartbreaking year for many of us, our families, friends, and colleagues, I offer these perspectives on what it taught us.

1. The policy was not in line with the times. Prior to the PHE, CMS limited telehealth access to only rural areas – and only at facilities designated under the antiquated provisions of the Social Security Act. Fortunately, Congress acted quickly to temporarily waive the geographic restrictions on telehealth and allow social communication technologies, such as FaceTime, to be used without repercussion. It is yet to be determined whether these waivers will remain in effect long term.
   Despite the uncertainty…
   
   
2. Telehealth became the safer, and sometimes, the only choice. Almost immediately, all routine visits and elective surgeries were canceled to accommodate the surge of COVID cases flooding our EDs and ICUs. Personal protective equipment was at a premium as we struggled to understand the epidemiology of this disease. “Tele-” (aka “distant-”) health provided a natural barrier between the virus and our caregivers, and it allowed our patients to be seen without in-person contact. In just two short months, we had completed over 80,000 such visits.
   Nonetheless…
   
   
3. Adoption was a choice. Even with the high demand for virtual care during the pandemic, there was no guarantee that telehealth would be leveraged to its full potential for various reasons. Lack of familiarity, technology hurdles and frustration, the perception (or reality) of creating more work for the caregiver, etc. Human nature will almost always gravitate toward the easier or more comfortable path if the change is not purposeful.
   And so, we learned…
   
   
4. It must be simple to use and readily available. The core tenets that “everyone knows how to use Zoom” and “everyone has a smartphone” turned out to be fundamentally flawed. In fact, nearly 1 in 3 of our patients were deterred by the so-called “every day” technologies that most of us in healthcare IT take for granted.
   This created its own challenge…
   
   
5. Keeping patients in touch with family was critical. One unintended consequence of restricting all visitation was the isolation that bore down on our patients. Solving this became a crucial use case for telehealth. Staff was using their own social media accounts and personal devices to make sure that patients could see their loved ones – sometimes for the last time. We now have purpose-built tools for patient-family communication and even a virtual companionship program for those who just need someone to talk to. Which supports the notion…
   
   
6. Telehealth aligns with consumer expectations. Perhaps for the first time in modern medicine, our patients want to choose when and how they receive healthcare services. They want convenience, access, value, and an overall positive experience. As such, telehealth aligns with consumerism in the same way that Amazon appeals to online shoppers. Why wait weeks to be seen in person by a specialist when an online consultation is available on-demand, 24×7?
   But this revealed…
   
   
7. Health inequity exists in telehealth, too. Our own data suggests that factors such as age, race, language, and socioeconomic status disproportionately exclude minorities with regard to access and utilization of telehealth.
   Which demonstrates…
   
   
8. The need for video interpreter services is growing. I consider it a requirement for almost any program today. Yet, it presents its own unique challenges in terms of bridging the connection at the right time with the right language interpreter. The promise of NLP translation – the likes of which Google already offers – would be a game-changer in this space.
   And yet…
   
   
9. Telehealth is exciting, but it’s not innately different. Telehealth is just another tool in the proverbial toolbelt. It will continue to evolve rapidly. And hopefully, in the not-so-distant future, it will become an integral part of how we deliver timely, quality care.
   That said…
   
   
10. Telehealth is not for everyone or every situation. We will never replace in-person doctor visits, at least not in my lifetime. Telehealth has its purpose, much like a hammer does with a nail. But thanks to COVID – as odd as that may sound – it has emerged as a practical and promising answer to many of the challenges we face in healthcare today.
    So, in conclusion…
    

Telehealth proved its value during the pandemic out of necessity. And now, we must not let it lose its luster. Telehealth has been a novelty for far too long. Today my organization considers it one of our top strategic priorities. We cannot allow this genie to go back in the bottle.

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COVID-19 accelerated the need for the healthcare industry to adopt and adapt emerging technologies.  During the pandemic, a brick and mortar facility became significantly less important than technology solutions that allow providers to care for patients remotely. Although telehealth is often considered an emerging technology, many telehealth tools have been around for years. For many providers, the use of telehealth technology had taken a backseat to in-person visits partially due to reimbursement limitations, but also in-person visits are “how we’ve always done it”. Change isn’t easy. 

Change is more easily accepted when the status quo becomes uncomfortable, unsustainable, or impossible. Patients on lockdown, afraid of in-person visits, and fear of the unknown created an environment where technologies that have been available for years finally emerged. Improved reimbursement and relaxed HIPAA requirements further accelerated the adoption of these “emerging” technologies, and as a result, patients and providers alike have become more accepting of these “new” technologies. 

Acceptance became adoption, followed by convenience in the new reality of remote healthcare. Emerging technology in healthcare is often more about adoption than it is about technology. Sometimes it takes the perfect storm to show the value technology provides in healthcare, and 2020 was that perfect storm to make telemedicine a cornerstone of healthcare. 

Innovative healthcare organizations that understand technology is a cornerstone have invested in creating virtual hospitals. Virtual hospitals will allow patients to receive healthcare from anywhere and reduce healthcare costs. Historically brick and mortar locations defined a healthcare organization’s identity and limited the organization’s service area. 

Technology becomes the great equalizer. Those who can create the emerging adoption of remote high-quality healthcare solutions will no longer be limited by geographic location. As more data becomes available, outcomes will improve and more services will be offered remotely. When patients are given a choice between an expensive hospital stay or the convenience of home, the paradigm will shift and today’s emerging technologies have become the norm. 

Technology Adoption Challenges

End-users (patients and providers) have different technical skillsets. Highly technical users are often frustrated when less technical users create a delay. The perfect example of this frustration is when you’re on a WebEx meeting, and one user delays the start of the meeting by 10 minutes because she/he is unable to figure out how to mute a microphone, use a camera, or share a screen. Less technical users are hesitant to use technology in fear they will be judged for not muting their microphone, not knowing how to use a camera, or share their screen. 

At our facility, a significant factor in preventing adoption is the lack of internet connectivity. A frequently used excuse is elderly retirees don’t use technology; however, we find many retirees use our technology services. 

Impacts of Technology

Patients are able to receive care where they are with remote visits, which saves them time and money.  Patients don’t have to take as much time off from work which allows their free time to be spent doing things other than taking care of healthcare visits. Providers are able to see more patients in the same amount of time when the technology works. Providers don’t have as much travel time for going to remote locations for follow-up visits which creates a better work/live balance.  

The negative impact is not everything can be done with today’s technology. At times, technology can accomplish 80% of what’s required, but the rest 20% take remote technology off the table. The true emerging technologies will be those technologies that overcome that 20% gap to allow even more to be done remotely. 

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COVID-19 has a significant impact on all industries and mainly healthcare. Many lives were lost and hospitals and healthcare workers had to deal with unprecedented situation dealing with the new virus. This pandemic forced everyone adopt to new ways of delivering care in a safe and cost-effective manner. COVID-19 became the Chief Transformation Officer in healthcare to provide care virtually using telehealth technology.

Though telehealth technology has been in the industry for over a decade, adoption has been slow for various reasons. However, pandemic forced everyone to offer care virtually to provide continuous healthcare to the patient population and to stay competent in the highly competitive healthcare market.

With big tech companies such as Amazon, Apple, and Google investing more in healthcare delivery, the healthcare market is becoming more competitive. Once big tech companies expand healthcare services through joint ventures with hospitals and health systems and with price transparency and restriction on surprise bills regulations patient population will be able to browse online and shop for the best healthcare provider less expensively instead of walking into an ER or Urgent Care Facility. At the same time, this is a great opportunity for innovative healthcare organizations to create a new line of business as telehealth hubs to provide telehealth on-demand care 24/7 by forming joint ventures with other tech and healthcare organizations.

1) Recent trends in mobile applications used in healthcare

• Pandemic forced everyone to implement and use mobile for various use cases such as Telehealth, integrating wearable devices with mobile apps to track health conditions, pre-visit registration paperwork completion and check-in prior to arrival, access patient charts, lab results, and radiology reports from anywhere, etc.
  
  
• Apps for healthcare organizations: inventory management, secure texting, etc.
  
  
• Apps for healthcare professionals: Telehealth, remote diagnostics.
  
  
• Apps for patients and family members: Health tracking apps, fitness/wellness, monitoring of chronic conditions such as diabetes, blood sugar, women’s health apps.

2) Recent trends in virtual technologies used in healthcare

• Virtual healthcare is changing from telehealth visits to more interactive consumer/patient-driven technology.
  
  
• New solutions for contactless care are evolving. Patients can enter all information via mobile phone or from home.
  
  
• Advanced analytics and BI tools, targeted focus on groups of high-risk patient population will be possible to send alerts via text, mail, etc to encourage getting vaccines, attend virtual health webinars, etc.
  
  
• The evolution of 5G broadband internet into the healthcare space will enhance the overall user and physician experience.
  
  
• As virtual care expands, it will provide more opportunities to work remotely for Clinicians and Support Staff.

Though telehealth and virtual care were in place for over a decade, adoption was very low because of lack of awareness, confusion in charges for patients, and reimbursement for healthcare organizations for in-person care vs virtual care.

3) Common adoption and operational challenges in deploying mobile applications and other virtual health tools in healthcare.

• Though telehealth and virtual care were in place for over a decade, adoption was very low because of lack of awareness, confusion in charges for patients, and reimbursement for healthcare organizations for in-person care vs virtual care.
  
  
• Other challenges:
  1. Lack of broadband and smartphones in low-income communities.
  2. Lack of regulatory enforcement
  3. Lack of incentives or subsidies to promote telehealth technology implementation.
  4. Security
  5. Interoperability
  6. Patient language
  7. Technology support for patients
  8. EHR integration
  9. Big data from discrete systems: How to consolidate and analyze data from remote monitoring and wearable devices in a physician friendly manner.

4) How to address the adoption and operational challenges in mobile applications and other virtual health tools?

• Incentives or grants to invest in mobile clinics and provide smartphones to low-income families.
  
  
• Evaluate reimbursement models, come up with some standards for care provided for in-patient vs virtual, and implement new incentives for organizations who meet some percentage of virtual care and penalties who don’t meet standards. Similar to the ARRA meaningful use initiative that helped promote EHRs implementation and adoption at most of the healthcare organizations.
  
  
• Invest in cybersecurity infrastructure and services.
  
  
• Lack of interoperability among disparate systems and different healthcare organizations is one of the major reasons for duplicate tests and higher cost of healthcare. EHR vendors and healthcare providers should break the barriers and share data for better patient care. Operationally this may be difficult in highly competitive Urban Areas, but if CMS defines some standards and rules regarding data sharing requirements, this should be possible.

5) How mobile health applications and other virtual health tools are transforming the healthcare industry?

• Proactive monitoring and real-time alerting via apps if there are any infectious disease outbreaks in certain parts of the world and precautions to be taken, so everyone is better prepared.
  
  
• Healthcare becomes more retail with virtual care and mobile apps. Patients can browse through and check for healthcare providers in a region, consumer ratings, cost estimates, any promotions, etc., just like online shopping.

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At Jefferson Health, our vision for a long time has been to blend traditional healthcare with technology to promote and create access. We spoke boldly about designing the future of healthcare and acted by heavily investing in workflow redesign, provider education, and technology. Purchasing and equipping providers with new technologies was only the beginning. Engaging each provider and providing them with the necessary education and workflows supported their eventual adoption of the latest technologies. This approach was key to a successful change in the provider’s mindset. From the onset, we understood that human factor engagement was crucial for providing a practice environment whereby providers would likely adopt the technology, thus leading to patient exposure and adoption of that technology. Success was defined as patient and provider adoption, improved access to care, and an increase in the total number of providers who utilized telehealth regularly in their practice. 

In the early days of telehealth adoption, our tagline was “anytime, anywhere” or “care without walls,” which was meant to describe removing barriers to care and our ability to create access to healthcare on the patient’s terms. This concept was born out of an obligation to meet our patients at their convenient place and in a way that was tangible for our patients and families. Now, those tag lines are outdated and telehealth is now simply considered healthcare.  

Necessity became the trigger for widespread telehealth utilization for our organization during our Covid-19 pandemic response. Given that the telehealth infrastructure was in place, our organization was able to quickly pivot to stay connected with our patients through the increased deployment. And while this may have been a foreign concept for many organizations that are new to telehealth and for Jefferson Health, this was more about our ability to right size and scale up when needed. Our organization buckets telehealth largely into two categories, scheduled visits with established patients and On-Demand, which serves as a direct-to-consumer 24/7/365 video urgent care model.

Our organization buckets telehealth largely into two categories, scheduled visits with established patients and On-Demand, which serves as a direct-to-consumer 24/7/365 video urgent care model.

In preparation for the “what if” Covid-19 would shut down in person ambulatory clinical practices, we took as disaster management approach in preparing and planning for this worst-case scenario. This took shape through a series of distinct approaches; assessment of platform audio-video capacity and bandwidth; provider and support staff educational readiness, operational access, workflow design, and how to conduct an effective physical examination utilizing telehealth. 

Admittedly, the ability to scale up telehealth capacity was envisioned to be when the policymakers, payers, and health care delivery systems would come to an agreement on payment models for this mode of care. Now, seemingly overnight, Jefferson Health was able to scale from a fractional amount of telehealth visits to nearly 90% of all ambulatory volume during the first wave of the pandemic. At the same time, On-Demand services saw a 15-fold increase. 

Suddenly, when faced with the prospect of lost revenue, limited access to healthcare, and fears of contracting Covid-19, providers were now more willing to engage their patients using telehealth. Prior to Covid-19, we would spend much of our time debunking the myths of telemedicine, specifically that it was “too hard”, and that telehealth visits were ineffective. Literally overnight, providers were not only able to navigate the system and refine their own workflow processes, but also were able to cultivate their own relationships with their patients through this mode of care. 

Years before the pandemic, our organization took a transformative approach to educate and train providers on the proper use of telehealth, including everything they needed to know about regulatory, risk, and compliance considerations as well as how to become facile with the technology itself. More importantly, we trained our providers on conducting an effective telehealth physical examination and developed video modules as part of the providers’ onboarding and competency training. These efforts, we believe, led to more rapid adoption and acceptance from both providers and patients alike.

Often, organizational culture and adoption of technology are met with a tepid response. End-users frequently feel put upon to adopt technology into their workflows while balancing operations and clinical care demands. In a changing culture, we needed to work to make this work for providers in order for patients to be presented with this as a viable option to receive their care. 

How should I approach telehealth at my organization? 

First, identify what it is that you are looking to solve for. This is a key approach in understanding whether telehealth is the right strategy for your organization. Below are some questions you may want to ask yourself as it pertains to your organizational decision on whether a telehealth strategy is a right fit for you:

• Does telehealth differentiate your organization in the market? 
• Does telehealth create additional access for patients independent of location (rural vs. urban)? 
• Does telehealth relieve other pressures within your organization, such as space allocation or schedule constraints? 
• Do my patients expect telehealth as a matter of convenience? 

If you have answered yes to any of the bullets above, your organization most likely will benefit from a telehealth program. While the decision to invest in telehealth is not done so lightly, the ability to implement with a provider and patient experience mindset is crucial for engagement and acceptance. A focused approach to train providers on how to conduct an effective physical exam and connect to their patients in a cohesive engaging manner will bridge most concerns related to any potential technology divides.

Telehealth has evolved and so has our thinking about how we should approach it. No longer should we speak about telehealth in terms of technology but simply as healthcare. As with most change management approaches, flexibility is paramount in any organization’s likelihood for successful adoption.

While the pandemic accelerated the adoption of telehealth, those who choose to engage telehealth more deeply as a solution will be best served by investing wisely in provider education in concert with workflow design initiatives. The likelihood of short-term adoption and long-term acceptance of telehealth into provider practice will largely depend on the providers’ comfort level in caring for the patient using telehealth while incorporating the technology into daily practice.

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Before 2020 there had been forward-thinking discussions on the consumerism of medicine, but the pandemic forced providers to focus on patient-centric care through telehealth, chatbots, remote consults, remote patient monitoring, and rich digital engagement tools. Fortunately, all stratifications of health care (payer, Medicare, and Medicaid) have benefited from this transformation. Some health systems saw up to 80% of ambulatory visits delivered by telephonic / telehealth encounters, but how do we ensure that all community members receive the care they need? 

According to the Centers for Disease Control (CDC), health equity is achieved when every person has the opportunity to “attain his or her full health potential,” and no one is “disadvantaged from achieving this potential because of social position or other socially determined circumstances.” Health inequities are reflected in differences in length of life, quality of life, disease rates, disability, death, the severity of disease, and access to treatment. Telehealth can improve health outcomes, reduce reliance on emergency room visits for episodic care, and reduce hospitalizations – all of which help meet health care’s quadruple aim – reduce cost, improve patient experience, improve quality and physician joy of practice. 

To determine how vulnerable a community is, we employ the Center for Disease Control (CDC) / Agency for Toxic Substance and Disease Registry (ATSDR), Social Vulnerability Index (CDC/ATSDR/SVI) tool that uses census data to determine the social vulnerability of every census tract. At AltaMed, by leveraging the CDC/ATSDR/SVI for social determinants of health (SDOH), we service and focus on the communities in the most vulnerable quartiles and overlay the SVI census track, and then geo-target by quartile of vulnerability. In April 2020, AltaMed Health Services started offering HIPAA compliant telehealth visits and they were not integrated with the Epic EMR. Today, we have full integration that allows the clinician to view the patient during the visit and invite in a translation service if needed. The incorporation of language services reduces language barriers is a key step toward health equity.

From May through December 2020, over 80,000 telehealth visits were completed. When it came time to vaccinate our patients, we used text messaging, email, and phone campaigns that leveraged the demographic data within our EMR to prioritize delivery aligned to CDC tier definitions. Furthermore, we broadly opened our vaccination slots to the community, so that everyone who wanted a COVID-19 vaccine could get one.

As we approach the midpoint of 2021, we look to broaden and continue extending our tele-footprint, including remote patient monitoring for Congestive Heart Failure (CHF). We enrolled a cohort of patients in January and have had promising results. We provide the patients with Bluetooth-enabled devices (weight scale, pulse oximeter, and BP cuff) and are taking daily measurements that are transmitted back to our virtual care team, where we can monitor changes in the patient and have a clinician intervene early. Daily rolling measurements are tracked and alerts are provided to the care team, enabling them to intervene versus having the patient go to the emergency room. Soon, we will be expanding this for Chronic obstructive pulmonary disease (COPD) and maternal-child/postpartum support for women.

Looking ahead from a care delivery perspective, with telehealth, we should have improved workflow, adoptions, and the technology should be easier to use for both providers and patients.

Looking ahead from a care delivery perspective, with telehealth, we should have improved workflow, adoptions, and the technology should be easier to use for both providers and patients. Primary care will see video specialty care, broader adoption for behavioral health, and routine care/nurse visits will become more prevalent. Quality outcomes will improve with advancements in remote patient monitoring that focus on the patient-centric home for those with chronic conditions.

We need to be careful that we do not revert to all our traditional care delivery models, maintain the focus to continue to strive and deliver patient-centric care that is consistent for all patients, and not lose the valuable legacy of learning from the pandemic.

Key Findings and Implications for the Future

1. Telehealth must be patient-centric, intuitive, and as simple as clicking a link. 
   
   
2. Insignificant broadband coverage can result in the patient defaulting to telephonic visits versus full video. We need to eliminate the digital desert that exists in socially disadvantaged communities that include urban cities and rural communities. Fortunately, there are national and state bills pending legislation review: 1) Life America Act for Health Infrastructure and 2) Broadband and Investments in America’s Health Infrastructure.

Providers should have the ability to work from anywhere and launch the tele encounter from a mobile device or laptop. Exam rooms may need to be altered to optimize telehealth visits and creation of telehealth centers of excellence is recommended.

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