Pandemic-Led Changes in Healthcare Delivery Will Last, Say Experts

Ken Terry

September 04, 2020

The COVID-19 pandemic has propelled rapid changes in healthcare delivery that are likely to stick around after the crisis ebbs, said representatives of Google Cloud, the Mayo Clinic, and Medically Home, a hospital-at-home company, in an online forum on Tuesday.

The three organizations are partnered in Mayo Clinics pilots of the hospital-at-home concept in Eau Claire, Wisconsin, and Jacksonville, Florida. Through this approach, patients with certain non-COVID acute conditions are cared for at home, rather than in the hospital, using a combination of telehealth, remote monitoring, and hospital equipment set up in the home.

"In the last 12 weeks during the COVID pandemic, we've made more progress [on hospital at home] than in the 12 years we've been around," said Rafael Rakowski, executive chairman of Medically Home.

The two main drivers of hospitals' increasing receptivity to the hospital-at-home approach, he said, are patients' fear of contracting COVID-19 in the hospital and the ability of hospitals to increase their COVID-19 capacity by caring for some patients virtually at home.

John Halamka, MD, president of the Mayo Clinic Platform, the organization's digital division, agreed that the pandemic has changed everything. When he joined Mayo in January, he recalled, Mayo's strategy was to reach certain goals in virtual care by 2030. "Then COVID happened, and what was a 2030 technology strategy became a 2020 technology strategy: the rapid acceleration of virtual care, remote monitoring, and the need to gather data from disparate sources and integrate them for situational awareness."

The use of telehealth, the biggest element of virtual care today, has fallen off recently after skyrocketing growth during the pandemic's initial stage. But Halamka said he believes telehealth is here to stay and will continue to grow.

Before the pandemic, he noted, "maybe some organizations were at 5% virtual, went to 95% virtual, and are now at 25% virtual, but they're going to stay at 25% virtual. So you went from 5% to 25% in 6 months. The cultural expectation will keep that going forward."

In addition, Halamka said, value-based reimbursement agreements make it advantageous to deliver "acute or advanced care in a nontraditional setting at substantial lower cost." And if state and federal rules create payment parity between telehealth and face-to-face visits, healthcare organizations will favor less costly telehealth encounters.

"This change is here to stay, and it's going to start at a baseline of 20% to 25%, and it will grow from there," he said. "It will never go back to 5%."

As the use of virtual care increases, Rakowski predicted, hospital executives will find it more difficult to justify investing in brick and mortar. "A CFO might have approval to build a new tower with 40 beds at $2 million a bed, and it costs $1200 a day to operate each of those beds. And he's saying, 'Do I really need to build that right now?'

"I heard someone say the other day, 'If you don't have backfill, a way to fill those empty beds, you better get a backhoe, because you're going to be razing your building.' "

Data Monitoring to Skyrocket

Halamka forecast "an explosion of sensor data" in the next couple of years. There will also be more automation, including AI-powered chatbots that will interact with patients, he said.

However, he emphasized, doctors are already overwhelmed by electronic health records, and they don't want to deal with streams of remote monitoring data. "Looking at 100 normal blood pressures isn't that helpful. Looking at a change in BP that's clinically significant and acting on it — that's helpful. That's our trick: build the capacity to receive all of this sensor data and route variations when they're clinically significant to the right person who can take action and close the loop."

Some physicians, Halamka observed, believe that telehealth is limited because it doesn't allow physical exams. "Well, ask yourself, what's the clinical significance of most clinical examinations we do?" he said. "What if you had a sensor that would give you real-time telemetry that would be able to provide qualitative, actionable information? We'll gather the data, filter it, apply algorithms, orchestrate it, and make sure the computers and doctors are working in harmony and not at cross purposes."

Rakowsky agreed that this is possible. But as new technology is substituted for some of the physical and analytic functions of clinicians, he said, "I worry that we start to rely on the technology as a substitute for the healing and caring role that clinicians provide to the patient."

Unlike other hospital-at-home companies, he said, Medically Home has a hybrid model that combines virtual care with clinician visits. "On day 1 and day 3, we send in a nurse practitioner from the [medical] command center to the home to initiate the visit and to check in on the third day. It provides a bridge between the virtual and physical worlds. It's expensive, but it humanizes the patient experience and brings in the family."

Medscape Medical News asked the panelists what kind of burden the hospital-at-home program places on patients and their families and whether that is an inherent limitation of the approach.

Rakowsky said that if the patient doesn't have adequate support at home or lives alone, "We provide a home health aide on the front end of care, when a patient is most highly acute." The role of that aide can be extended, he noted, if the patient doesn't have the necessary support at home for activities of daily living.

"An average hospital day has fixed costs to the hospital of between $1200 and $1800," he added. "That's a lot of money to be able to spend on all the services a patient needs at home. The financial idea is very compelling and allows more care over a longer period of time."

Moving Beyond Geography

Aashima Gupta, director of global healthcare solutions for Google Cloud, pointed out that advanced virtual care platforms can allow healthcare organizations to deliver care to patients outside of their service area.

Halamka concurred: "We're piloting [the hospital-at-home concept] in Wisconsin in a somewhat rural setting, and there's not huge access to capital to build more facilities. As a result of Medically Home, we can see twice as many patients. We can use the same expertise and the same staff but not have to build more bricks and mortar. So this is great for everybody."

Rural areas don't necessarily have the requisite infrastructure, he explained. "Broadband access is not universal, but cell service is pretty good in most of the country. Medically Home includes a built-in LTE modem that can carry signals over the cell network, even if you don't have a cell phone," Halamka said.

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