Digital Health Explained: Making Patient Care Easier

An Interview With Sumbul Desai

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Editor's Note:
Guest Sumbul Desai, MD, of California's Stanford University and Stanford Health Care, reviews the tech companies and innovations that healthcare providers should be aware of and explains how digital health can enhance rather than replace the physician-patient interaction.

Sumbul Desai, MD

Robert A. Harrington, MD: Hi. This is Bob Harrington here on Medscape Cardiology and theheart.org. Over the course of the past year, we have had a lot of discussions about the role of technology in both cardiovascular care as well as cardiovascular research.

One of the topics I wanted to explore with our guest today is digital health. Digital health, obviously, has a lot of meanings, but I want our guest to really dive into what she thinks of digital health—what it means today in the care enterprise as well as in the research enterprise—and walk us through some of the issues and successes in digital health, some of the challenges, and perhaps give us some examples of how digital health may actually help transform cardiovascular care delivery.

Our guest today is a friend and colleague of mine here at Stanford University: Dr Sumbul Desai. She is an assistant professor of medicine. She is an associate chief medical officer for the Stanford Health Care System and the vice-chair of strategy and innovation for the Department of Medicine. Sumbul, thanks for joining us here on Medscape Cardiology.

Sumbul Desai, MD: Thanks so much for having me.

Dr Harrington: Sumbul, you heard my intro remarks that over the course of the next 15 minutes or so, we want to explore digital health. Before we launch into the broadness of the topic, can you help focus our audience and explain what we mean when we talk about digital health?

Dr Desai: Digital health, as you have alluded to, is a broad term and basically describes the use of digital technology to collect [and] share [information], and interact with patients and providers. It's using technology to share health information as well as focus on health wellness and improving healthcare in systems and outside. The way I think about digital health is that it includes elements of technology and service (which we can get into); mobile health, wireless connective health, big data, wearables, telemedicine, personalized health, and physiologic sensors all fall into that space.

What you are also starting to see now is a number of service companies—such things as new accountable care organization (ACO) models. There are such companies as Collective Health that leverage technology, but are focused on the delivery using a variety of different payer models and employer models as well.

[Digital health] has become a broad term. The way I think about it is really, how do you use digital information, technology, and service to improve overall health and wellness?

Dr Harrington: That is a great definition and, as you have nicely pointed out, it does include a lot of different pieces. A lot of folks think of it as just utilizing technology to replace face-to-face care delivery, but I do not hear you describing that. You seem to be describing it more as technology used to augment or improve care delivery. Do you want elaborate on that?

Video Visits: Learning From a Failed Experiment

Dr Desai: Yes, absolutely. You honed in on one of my biggest pet peeves about [misunderstanding] digital health.

When we started at Stanford, we were focused on all the exciting things the technology could do when we rolled out, for example, video visits about 3 years ago at Stanford. We rolled it out in our primary care clinic, and we did not put any time or thought around how to integrate it into the care model. We just said, "Okay, let's turn on video visits, and everybody is going to use it." Honestly, it was quite a big fail, which I think we learned a ton from; in essence, it did not turn out to be a fail because it was actually a great learning [experience] for us.

The focus on digital health is really, how do you use technology to improve the interactions with your patients and between providers as well? How does it augment the delivery model? In my previous life, I worked in entertainment, where you focus on the different distribution channels of entertainment product. If you think about clinical care as your product, then it's how do you use technology as a new channel to augment your relationship?

The in-person relationship is still really important, but it's about using technology to make the communication and the interactions with physicians and between providers easier. When we have rolled things into an overall service model with a lot of thought around the education for the patient, [and] the education for the physician, on how they use the digital technology and how it can augment as opposed to replace interactions, we have had much better luck with its uptake. That is one of the things that we often have to remind our technology company counterparts of here in the valley: The technology is incredibly important, but it is just a piece of the puzzle, especially in healthcare delivery, in terms of how to use digital health.

Dr Harrington: That is a great description. We'll come back to that when we talk about virtual primary care and maybe some of the things that our cardiovascular audience will find interesting, particularly around preventive mechanisms of using technology for such things as weight-loss counseling, exercise counseling, et cetera.

Talk to us, Sumbul, about the scope of digital health. You have alluded to the fact that this has become a ripe area for technology innovation, maybe even technology disruption; there are a lot of companies forming around this. Give our listeners a sense of the scope—whether that is numbers of companies, dollars involved, venture investment, any of those metrics.

A $4.5 Billion Industry

Dr Desai: In 2015 alone, digital health investment was about $4.5 billion.[1] That's venture funding, so that gives you a sense of the scope and of how they are looking at it in the [Silicon] Valley.

I will talk about it in a few different metrics. Often, it is not just Silicon Valley looking at digital health; it is many large companies across the United States. With the amount of time and money and the percentage of gross domestic product (GDP) that healthcare accounts for, many people believe that healthcare is the next space that is right for disruption. I would say the three top areas that people talk about for disruption are health, education, and transportation. A lot of interaction and a lot of investment are being spent in those spaces.

Another interesting metric is that about 270 companies raised over $2 million [each] in 2015.[1] In this past year, you are seeing the digital health investment continue to increase. It is not going down, even though venture funding is drying up in certain areas in some of the consumer spaces. It has actually overtaken medical device investment over the past 2 years.[2] You are definitely seeing a shift in focus into digital health.

The last thing I want to mention is the estimated telemedicine funding and gross year-over-year growth, which is above 30%-40% over the next few years in terms of utilization of telemedicine visits. It gives you a sense of scope, and obviously the ubiquitous nature of mobile devices is contributing to that. Does that answer your question?

Dr Harrington: It is incredible to think about it not just in terms of the venture investment, but relative to, for example, the investment in medical devices. It shows how quickly the investment in the way that we deliver technology to our patients can really change.

Let us now talk about some of the people that you would say have succeeded in this field. I realize we are still in many ways in a nascent field. It is evolving. As you say, healthcare is perhaps one of the great areas of potential disruption, but a lot of what we do is still the way we have always done it. Can you give our audience examples: maybe some of the academic places or large community-based health systems that have used technology pretty well, and maybe some of the companies that you think are particularly interesting and that our listeners might want to either check out or pay attention to?

Dr Desai: Let me first start by saying that one of the companies that has done a really good job using technology (and many might cringe when I say this) is Epic [Systems]. But actually if you think about Epic in terms of its growth and valuation.

One of the companies that has done a really good job using technology (and many might cringe when I say this) is Epic.

Dr Harrington: We will get some comments about that, I am sure.

Dr Desai: You will, but at the end of the day, when venture capitalists (VCs) are looking at digital health companies, they look at companies with electronic medical records (EMRs) as well. It is considered the earlier side of the spectrum of digital health—not necessarily where the future will go—but such companies as athenahealth who have done a take on the EMR and really thought about engagement and how to improve physician workflow are doing amazing work.

Every large company—for example, the Apples and the Googles of the world—are doing things in healthcare that will yield some interesting things, despite a lot of critics saying they have not done anything amazing yet. ResearchKit has changed how you enroll patients in research studies, and that is not a minor feat; to get physicians to start changing workflow is really interesting.

In terms of the exciting things on the horizon, there have been a number of companies that have done a lot of good work with employers, such as Castlight Health and even companies like Doctor On Demand; they have gotten into the employer space and are offering video visits. Large insurers are offering Doctor On Demand as part of their overall insurance product. It is pretty remarkable, if you think about it. I met with Doctor On Demand not even 3 or 4 years ago, and these companies did not exist. They were companies on paper, and they are now part of very large payers, such as Aetna and United. That is a virtual telemedicine company.

Going back to some of my earlier comments, my whole take on digital health is, how do we make healthcare easier? There are some interesting companies in that space. There are two companies, called NimbleRx and PillPack. NimbleRx does on-demand pharmacy delivery, and patients absolutely love it. It has been a real game-changer in terms of improving convenience in healthcare.

What PillPack does is curate your pills into a nice single packet for those who have chronic diseases and take a number of medications. Every month, you get a roll of pills that you then take out, and it has all your medications already prepackaged by time—eliminating the use of your medicine box, if you will. They are adding a digital component to it, with reminders and things like that.

Then, there are companies such as Iggbo (which I just learned about recently). They are doing on-demand phlebotomy, thinking again about how to use technology to improve convenience. You can actually schedule the time that a phlebotomist will come to your house and do your lab draws, and then all the lab results are interfaced through a mobile app and connect back.

There are a number of cool companies in the big data space. Such companies as Flatiron Health are taking informatics and data and doing predictive modeling in the cancer space. They did a nice presentation at the American Society of Clinical Oncology (ASCO) meeting recently.

Then, there are companies in the cardiology space that are really interesting. I think they still have not figured out their market quite yet—companies like AliveCor, where you can do a one-lead EKG on your phone. I think it is interesting, but they are struggling a little in terms of figuring out the right market to position themselves in.

Those are some of the companies that are doing some really interesting work. In terms of where it can go, the thing that I am most excited about is, how do you drive healthcare into your normal consumer interaction. Bob, you and I have talked about Amazon Echo and the Alexa platform. If you think about its use for health, there is a lot of exciting activity that could happen. Boston Children's [Hospital] has been a great leader in innovation; they recently rolled out an app with Alexa. That could have a broad impact if we start thinking about how to personalize health habits using devices like Alexa to help you get to your goals.

There are two big leaders in the community hospital space that are doing some really interesting work: Cedars-Sinai [Medical Center] and Dignity Healthcare. What they do really well is to integrate the innovations into their clinical workflows and roll them out really fast. They have had a lot of luck partnering with startups and are doing a nice job by having patients engage in use.

That overview is just to give you a broad brush of some of things I find interesting. I think those systems, per se, have done a really good job with moving the needle forward.

Dr Harrington: That is just a fabulous overview of a field that seems to be changing weekly, with new companies, new players in the field, et cetera, so thanks for walking us through it.

Reimbursement Challenges and Patient Satisfaction

Dr Harrington: We have talked about some of the really interesting things. What about the challenges? Some of the things I hear, Sumbul, in my travels include, "Are patients satisfied with this type of care delivery? Are doctors and other healthcare providers satisfied with these types of tools? Have the payers figured out the reimbursement issues?" You mentioned some of the payers incorporating telemedicine into their offerings, but have we figured out the reimbursement issues? Those are the three questions I hear.

Dr Desai: You are spot on. I would say that reimbursement is still the greatest challenge in digital health. Many of the companies that come to speak to us in the healthcare systems really have not thought through the business model. A lot of companies are going to such employers as self-insured employers; that is an area that is getting a lot of attention, because if you can get the employer on board to pay for your tool, then you have a reimbursement model. In general, the Centers for Medicare & Medicaid Services (CMS) has been slow to acknowledge [digital tech]—and rightfully so, because they really want to see more outcomes before they agree to assign reimbursement across the board.

There are a number of challenges, and reimbursement is a huge challenge. There have been many bills presented both to state and federal legislatures in terms of passing reimbursement, but the uptake has been very slow in general. The reimbursement issue makes it challenging for physicians to engage, because so many physicians are already so busy with the workflows that we currently have; to add another thing where they potentially may not be reimbursed is a real challenge.

I will give you an example. Both in dermatology and cardiology, you could imagine someone virtually being paid for EKG reviews and figuring out models to do that. Many systems have not figured out how they expand that. This has happened with dermatology and reviewing of pictures and photos. For example, at our own system, we have dermatologists reviewing photographs from other physicians, and you can imagine the same thing with EKGs, if you were to have a physician review your EKG. We still have not figured out the reimbursement model and how to avoid having these providers spend time doing pro bono consults, and instead reimburse them for it. I think that has been a big challenge in terms of uptake.

Then, there is the education piece that has been challenging both for physicians and patients. With some of the work that I have done in the past, what patients have really struggled with is understanding that the quality of the physician with whom they are interacting when they are virtual or through these mobile health companies is of the same quality as the physicians whom they would see if they saw them in person. There is a huge education component that needs to go around the roll-out of digital health, with patients and for the physicians too. Physicians still struggle with their email. Again, we are so busy that to be able to learn something new, we need to feel that there is an upside to it. That is not quite clear.

Integration with Epic is a huge challenge, in the sense that many of our systems now have this EMR and if these digital health tools do not integrate with the EMR, you are adding additional workflow for physicians if they have to also interact with these digital tools. That is just really difficult to do in busy provider schedules.

There are many challenges; these are just a few of them.

Dr Harrington: One of the things that comes out through all of your remarks is that we need to do research in this area to understand such things as outcomes, satisfaction, [and] quality of care, just like we have studied through health services research and other forms of delivery. This is an area of delivery that is ripe for investigation and ripe for research.

In the last couple of minutes, Sumbul, can you describe your experience with our virtual primary care offering at Stanford, which you have termed ClickWell? Just quickly give the audience some lessons that you have learned from creating this virtual care offering for our patients—some of the key successes and some of the key challenges, and how our patients like it.

Dr Desai: Very quickly, ClickWell is a virtual primary care clinic where we try to offer end-to-end health. We leverage technology to help support that, so patients can pick virtual in-person visits as well as working with a wellness coach virtually. Some of the lessons that we have learned: Keep it simple—the easier you can make something for a patient to interact with, the better uptake you are going to have. That is one thing that we have learned. As much as you can focus on connecting convenience and using technology to make it convenient for patients to use, they are going to have a better uptake, so that was a big lesson for us.

To your point, another big lesson for us has been to track everything that we are doing so that we can constantly iterate. Not only is the research helpful to prove the outcome—the data and the research in every aspect of what we are doing—[but also] collecting [information] is really important to continue to iterate and put out a better offering. We have really focused on leveraging data to be able to do that, and that has been incredibly helpful.

I have touched on many of the challenges, but some of the other challenges and lessons to think about are really knowing and understanding and listening to your patients, as well as your providers if you are doing a provider-facing digital health tool. You need to understand where the pain points are and everything about the workflow so that you can improve upon it.

Another lesson, which I touched on earlier, is [that] it is not just about the technology; really think about how the technology flows into the overall care model, and how you are going to deliver the care differently in services leveraging the technology. That is really important.

Then, [there is] breaking down the silos. What I mean by that is, how can you leverage technology to create more of a virtual health system that actually talks to each other and connects? How do you break down the silos between cardiology and primary care, and dermatology, and oncology? How do we all work together and make it easier for patients to interact with us? At the end of the day, when they are working with us, it is often five different touch points; how can we leverage technology to actually make it one touch point that then does all the work on the back end?

From a patient-centered focus, those have been some of the lessons, and that has been a little bit more of my bent—to really think about it from the patient's perspective, [and] how they interact with these tools.

Dr Harrington: I think the way you have ended it is a perfect summary. Maybe I will say two things—one of which is, think of the technology in a way that integrates with the system as opposed to replacing something in the system, because by integrating it, hopefully we can give our patients and our physicians better experiences themselves. Second is [that] we need to constantly measure and iterate and report back, because that is how we are going to learn where we are from a research perspective with the technology and then, ultimately, the care offering is going to get better.

Sumbul, thank you for joining us here on Medscape Cardiology. This has been a terrific discussion of digital health. My guest today has been Sumbul Desai, an assistant professor of medicine at Stanford, and associate chief medical officer in the Stanford Healthcare System, and the vice-chair of strategy and innovation for the Department of Medicine. Sumbul, thanks for joining us.

Dr Desai: Thank you for having me.

Disclosures: Sumbul Desai, MD, has disclosed no relevant financial relationships.

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