Achieving Digital Health Equity: Is it a "One-Size-Fits-All' Approach or Personalized Patient Experience?

July 11, 2023

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Panelists: Elizabeth Krupinski, PhD, FSPIE, FSIIM, FATA, FAIMBE (moderator); Priya Bathija, JD, MHSA; Jorge Rodriguez, MD; Tara Sklar, JD, MPH

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00:00And I'm going to welcome in our next panel,
00:03Panel 2, which is going to be moderated
00:06by Doctor Elizabeth Krupinski on
00:08achieving digital HealthEquity.
00:10Is it A1 size fits all approach or
00:12personalized patient experience?
00:14And just a brief word about Doctor Krupinski,
00:17who I've known now for several years
00:19and professor and Vice Chair for
00:21Research in the Department of Radiology
00:23and Imaging Sciences at Emory.
00:25She's an experimental psychologist
00:26who has thought a lot about.
00:29Decision making and image perception,
00:32you know, thinking about how
00:33human factors pertain to the,
00:36the activity of the of the provider and
00:40I think is going to lead us in a really
00:42interesting conversation on this topic.
00:44So with that, let me turn it over to
00:46Elizabeth and have you take the floor.
00:48Great. Thank you very much.
00:50That's a great session and.
00:53I think we got a really exciting
00:54one coming up now as well.
00:56As Lee said, this is all about
00:58achieving digital HealthEquity. Now.
01:00You know what's the rationale for this,
01:02this session in this conference?
01:03Well, as was noted,
01:05COVID saw this huge increase in the use
01:09of digital health supporting its utility,
01:12its benefits.
01:13It revealed a lot about what
01:15is feasible and you know,
01:17people were engaged in it and and
01:19doing telemedicine and we really
01:21saw where it can be of help.
01:23The problem is,
01:24although it's appropriate in many,
01:26many specialties,
01:28what COVID did unfortunately was
01:30also unfortunately reveal what the
01:33limitations and gaps are that we still
01:35have to face and one of the biggest
01:38gaps that really became quite evident
01:40and sometimes in surprising ways.
01:43Was that there's significant digital
01:46HealthEquity issues and so this panel
01:49is going to discuss 3 aspects of
01:52issues and solutions to some real
01:55live digital HealthEquity issues
01:58using real case examples and we
02:01brought together 3 awesome people.
02:03And I'm just going to do very
02:05quick introductions and then we'll
02:06get into the presentation.
02:07So our first speaker is going
02:09to be Jorge Rodriguez,
02:10a physician from Harvard University.
02:13He's an instructor there,
02:15clinician investigator interested
02:17in exploring bridging the digital
02:19divide in healthcare.
02:21He's currently funded by the NIH to
02:24study technology equity especially.
02:27Extending telemedicine to Latino
02:29patients with type 2 diabetes.
02:31So he is going to start out giving
02:33us an introduction to what the
02:35domains of HealthEquity are.
02:37You know the term gets thrown around a lot.
02:40What is HealthEquity?
02:41What is digital equity?
02:42And so he's going to really give us the
02:44domains and talk about some specific,
02:46ample examples of what HealthEquity
02:49really is all about.
02:52Then we're going to hear from Priya.
02:54Buthesia,
02:54she is a lawyer from Loyola University
02:57and she is also the vice president
03:00of strategic initiatives at the
03:02American Hospital Association.
03:04And she has basically looked
03:06at years designing,
03:07implementing growing initiatives
03:09that help people basically lead
03:11healthier lives and how do we
03:14integrate technology into all of that
03:16and to address their social needs.
03:18Then finally, we're going to hear
03:19from Tara Sklar, another lawyer
03:21from the University of Arizona,
03:23where she is a professor and director
03:25of Health Law and Policy Program.
03:28She's also the senior advisor in
03:30the Telehealth Law and Policy for
03:32the Arizona Telemedicine Program
03:34and innovations in Healthy Aging.
03:36And she looks at legal and regulatory and
03:39ethical issues that arise from, you know,
03:42adopting technology into aging populations,
03:45health populations, and so on.
03:47So without further ado, I'm gonna
03:49turn it over to Jorge and then each,
03:52the speaker's just gonna hand
03:53it off to the next one.
03:55And then at the end, if we have time,
03:57we're gonna open it up for some discussion.
03:59So it's all yours, Jorge.
04:01Great. Thank you so much.
04:02Thank you everyone for the invitation and
04:04I'm really excited to speak with you all.
04:07Today we can move to the next slide here.
04:10I'm hoping that you know over the next
04:1210 minutes or so as we chat here,
04:13you'll probably take away three things.
04:15One, think about how to
04:17define Digital HealthEquity.
04:18Two, why are we even talking about this now?
04:20And three, hopefully spend most of our
04:22time discussing how do we actually go
04:24about achieving Digital HealthEquity.
04:25You move to the next line.
04:27And when I think about digital HealthEquity,
04:28I like to think about in the context
04:30of everyone having a fair and just
04:32opportunity to engage with and
04:34benefit from a digital health tools.
04:36This is borrowed from a HealthEquity
04:38definition which defines this at the
04:40medical level to say everyone should
04:42have a fair and just opportunity
04:43to benefit from medical care.
04:45In this case,
04:46we're using digital health tools
04:47and when I talk about digital
04:49health tools to the next slide.
04:51I primarily talk about a lot
04:53of patient facing things,
04:54so things like mobile health apps,
04:55patient portals,
04:56remote monitoring,
04:58telehealth texting solutions,
04:59it kind of goes on and on.
05:00But things were we're having a being
05:03discussed in the prior panel that that
05:06relationship with patients and technology
05:08facilitating that that aspect of it.
05:10We can move to the next slide.
05:12And so why are we talking about this now?
05:14We've,
05:14you know,
05:14it's been wonderfully set up in the
05:16prior discussion around the the rise of
05:19telehealth over the past two to three years.
05:21In addition to that,
05:22you know,
05:23we had the,
05:23you know during vaccine deployment
05:25we often relied on online based
05:26scheduling tools and that kind
05:28of brought to the forefront that
05:30certain populations just didn't
05:31have access to the Internet.
05:33And these are often the populations
05:35that were more most significantly
05:37affected by the COVID by COVID-19 and
05:39the third one and perhaps you know,
05:41slightly less.
05:42Let's discuss is the enactment of
05:44the 21st Century Cures Act which
05:46really put into place a law that
05:48empowered patients and and and made
05:50it so that patients had easier access
05:53to their to their healthcare data.
05:55So really encourage patients to now
05:57and you know interact with their
05:58healthcare data and of course that
06:00requires going online and a couple
06:02of the other things that we we'll
06:04get to and the rest of the time we
06:06have together here and so but when
06:08you think about this even before the
06:09pandemic a lot of these challenges
06:11that we talked about in the.
06:12Visual HealthEquity space, we're there.
06:14If you think about high tech act and
06:16the development of patient portals,
06:17for example,
06:18if you look at the early patient
06:20portal literature,
06:20you find a lot of gaps in terms of
06:22who is using and accessing these
06:24tools by marginalized populations.
06:25So it's not surprising that in
06:28our next slide.
06:29We had this come up during this is,
06:32this is data from early on in the
06:34pandemic from our organization
06:35where we saw significant disparities
06:36in the use of video visits
06:38amongst marginalized population.
06:40So we sort of saw this coming
06:41a little bit, but I think,
06:43you know I think this really gives
06:44us an opportunity now that we're
06:45sort of really committing to this
06:47effort to say how can we reimagine this,
06:49how do we go about next slide
06:53achieving digital HealthEquity.
06:55So, so that's, that's what I'm
06:57hoping to spend the rest of the
06:58rest of the time on here today.
07:00And so when I think about Digital
07:01HealthEquity, I primarily think about
07:03it across 5 domains, next slide.
07:06And those domains are technology.
07:07And it's it's just like there's a lot of,
07:09there's a lot of meat here.
07:10So just I'm going to try to hit
07:12on each of them briefly here,
07:13but technology, access, technology,
07:15literacy, implementation policy
07:17and standard of care next slide.
07:20Technology access is the one that
07:22everyone kind of thinks about, right?
07:23Classically, the digital divide,
07:24those who have access to the
07:26Internet and those who who do not.
07:28But there's a lot more there, right?
07:29There's a whole discussion around broadband
07:32infrastructure and who had that actual,
07:34you know,
07:35Internet lines or Wi-Fi
07:36signal getting to their home.
07:37That's a whole discussion there.
07:39There's also the components of
07:40not only having that reach your
07:42home or reach your device,
07:43but are you now able to afford it?
07:44Are you able to afford the broadband,
07:46afford the device?
07:47And then the other poke piece I'll
07:48get to a little bit later is the
07:50role of the healthcare system in
07:51serving as a as a as a touch point
07:53to say are we going to screen
07:55for these things and then refer
07:57to the appropriate resources.
07:58And then one that I I haven't
08:00noted in the slide here,
08:01but I think it's super important.
08:02It's more of a structural component
08:04here and this is where the role
08:06of digital redlining or digital
08:08discrimination comes into play.
08:09And for those,
08:10for those not in the know,
08:11digital redlining and build discrimination
08:13refers to a practice by Internet
08:15service providers in which they kind
08:17of deploy their Internet services in
08:19ways that disadvantage certain groups.
08:21So in a sort of a simple example
08:23would be there are certain areas
08:25where deploying very slow speed
08:26Internet at high cost.
08:28Or or they say they're
08:29offering a plan that's like,
08:30you know,
08:31$50.00 a month across a
08:33whole geographic area,
08:34but in certain areas are
08:35slowing the speeds down.
08:36So it's not the fact that no one's
08:38actually getting the same Internet
08:39speed and they're kind of making
08:41these choices and that's often called
08:42digital redlining or cheer Flattening
08:44is another term that you might hear
08:45and this is more of a structural,
08:47structural piece of this.
08:49So that's about technology access next.
08:52But having having access to
08:53the Internet is one thing,
08:54being able to use it effectively is
08:57another when you have it in your hand.
08:59And so in the next line,
09:01I sort of highlight three things I
09:03think about one, it's the platforms,
09:042, it's having a one-on-one support.
09:06And three,
09:07how do we work with community organizations.
09:09And in the next line,
09:10I'll tell you about one of my
09:12favorite studies, a simple study,
09:13but so good here was they took
09:16a series of patients,
09:17they gave him a chronic disease.
09:19Focus apps and they ask them to complete
09:21data entry and data retrieval tasks.
09:23And the patients were only able to
09:24complete about 50% of the tasks.
09:26So if you can imagine your favorite app,
09:27you know, I presume it's going
09:29to be a social media app.
09:30Let's say you're using Twitter
09:31or Instagram or something.
09:33If you're only able to post to it
09:34but not actually look at anything,
09:36it probably wouldn't be a very useful app.
09:37And so this isn't from a design perspective,
09:39this is the kind of environment
09:41our patients are seeing.
09:42And in the next slide.
09:44And so you sometimes,
09:45even if you designed the technology
09:47to be the best,
09:48you might need some extra
09:49support and extra help.
09:50And there's increasingly the use of
09:52digital health navigators to help people
09:54on board or use these technologies as
09:56new members of the healthcare team.
09:57We had a digital health navigator
09:59pilot that I was closely related to
10:01one of our primary care clinics where
10:03we reached out to around 400 patients
10:05trying to get them to enroll in the portal.
10:07We were able to contact most of them
10:10and then we enrolled about a third
10:12of them and then of those that we
10:15enrolled about 8080% or so actually
10:17logged into the portal again and
10:18that was our measure to say this
10:20one-on-one support really made a
10:21difference in in connecting patients
10:23with this new tool and making it part
10:25of the something that we're using
10:27over the long term in the next slide.
10:29I just sort of make the point that,
10:31you know, we often did.
10:32As we've kind of gone through this process,
10:33we've often been like,
10:34oh, wow,
10:34how are we going to teach
10:35patients how to do this?
10:36And digital literacy,
10:37really not unique to healthcare.
10:38There's a lot of folks in adult
10:40education and youth education that have
10:42been working on this for a long time,
10:44perhaps not in the context of health,
10:45but in the context of civic engagement,
10:47workforce development.
10:48There's a lot to learn from
10:50that from those folks too.
10:51So I think it's an opportunity
10:53for us to do that.
10:54And then the next line,
10:56we'll talk about
10:57implementation considerations.
10:58From an implementation standpoint,
11:01next slide also highlight three things here.
11:03One is fairly simple,
11:04looking at looking at your
11:06use across demographics,
11:08but the other thing is showing
11:09it to the right people,
11:10the people in leadership,
11:11so they can review these dashboards and say,
11:13hey, we just deployed this new digital tool.
11:15How can we go about, you know,
11:17we're noticing these gaps,
11:17what do we have to deploy
11:19to address those pieces?
11:20The second one is all around workflow.
11:22So you know,
11:23when we looked at some of the
11:24use of telehealth for example,
11:26we found that it wasn't just patient
11:27factors that were driving some of the
11:29disparities in telephone versus video.
11:31There's a lot of like clinic level factors,
11:34provider or clinician level factors.
11:35So having those workflows in place,
11:37for example, you know,
11:39easy way to include interpreters as
11:42part of like a telehealth visit,
11:44you know drives a big point in kind of.
11:49Thing that I often think about and and
11:50was were brought up a little bit in the
11:52previous panel was about privacy and trust.
11:54So if you go to the next slide
11:56when we talk to think about a lot
11:58of these things that are like they
11:59sound really great, right.
12:00They're like okay,
12:00we're going to you know monitor you remotely
12:02but for certain patients that you know
12:03if you think about it in a different way,
12:05it's like I'm looking at you remotely
12:06from afar when you're not maybe.
12:08And so making sure that as we're collecting
12:10this data which I think is great,
12:12we make sure that we're not sort of
12:14falling into the trap of some other
12:16technologies which have not been great with.
12:19Privacy and for certain marginalized
12:20populations like undocumented
12:21immigrants for example,
12:22we want to make sure that them accessing
12:24care through these tools doesn't bring
12:26up sort of other issues for them.
12:28So I think it's important for us to
12:30consider that those pieces as well.
12:31And then we go to the next,
12:32the next slide and the last part of
12:34it and the last part of this section
12:36is around engaging patients and
12:37families and we go to the next slide.
12:40And this one's about just creating
12:42multimodal care here.
12:43This is an experience from one of
12:44our digital health navigators.
12:46You talked to one patient who thought
12:47the portal was the best thing ever and
12:49you talked to another patient that was
12:51like I don't want to engage with this at all.
12:53And so there's some component of
12:54patient preference that comes into
12:55play and we have to build a system
12:57that not only allows for all these
12:58great you know technology tools for
13:00some for allows for non non digital
13:02options for those patients that may
13:04not want to use those use those tools.
13:06Next slide. And then we move to policy.
13:10In terms of policy,
13:11the main point here in the next
13:13slide is around the Infrastructure
13:14Investment in JOBS Act,
13:15which passed earlier this year
13:17and this was a whole as a whole
13:19section on digital equity.
13:20I think this is a real.
13:21You know,
13:22a real change to the foundation
13:23where we're starting from.
13:24It really takes a lot of the issues
13:26that we're facing in terms of
13:27technology access and literacy.
13:28It tries to take them away only
13:29from like all the healthcare,
13:30the hospital has to do something and
13:32brings them out into more like the
13:34public or the the kind of federal space.
13:35And I think it provides a lot
13:37of opportunities, for example,
13:38an Internet subsidy for patients that
13:40may not have access to the Internet.
13:42It provides money towards building
13:44out digital literacy programs,
13:45again working with community organizations.
13:47So I think this is a lot,
13:48a lot that's going to really push
13:50things forward and then the next.
13:51Slide from a healthcare organization
13:54standpoint, you know I think
13:55I'd highlight the main things.
13:56I think it's you know being able to
13:58refer patients to these programs.
13:59I think it's one big opportunity
14:01for healthcare organizations.
14:02The other one is serving as stakeholders
14:03and a lot of these discussions
14:05are on digital discriminations.
14:06As we collect more of these digital
14:08needs screening information,
14:09we're going to be able to tell
14:10which patients are struggling,
14:11which Internet service providers may
14:13not be providing the best service
14:14and we can have sort of advocate
14:16for our patients like if we're
14:17going to deploy our remote blood
14:19pressure monitoring tool and in a
14:20community that's being affected.
14:22By digital redlining or tear fattening,
14:24we're sort of fighting an
14:25uphill battle already there.
14:26So making sure that we're having
14:29those discussions up front.
14:30And then the next slide lastly is
14:33viewing this as standard of care.
14:34The main point I make here is that
14:36there's some data suggest that only
14:37certain patients are offered these
14:39tools and we as clinicians and
14:40provider pay a big role in kind of.
14:42Pushing this as like this is
14:43the way we're delivering care.
14:45At least let's have a conversation
14:46about it and I think making sure we
14:49don't make pre assumptions about who's
14:50going to use technology and who is not.
14:52And the last point I'll leave
14:54you with here is that, you know,
14:56I'm an informatician technophile,
14:57love technology,
14:58but we want to make sure that we
15:00keep our eye on the prize here.
15:01Our in the prize is digital
15:03HealthEquity to some extent,
15:04but only to the extent that it
15:05gets us to our ultimate goal,
15:06which is really, really HealthEquity.
15:09So with that, thank you so much for,
15:10for listening and I'll pass
15:11it on to my colleague.
15:13So much.
15:14Awesome. Thank you, Priya.
15:18Great. Thank you, Elizabeth.
15:20I'm really excited to be here
15:23today and happy that to be
15:25included as part of this panel.
15:27So today already we've had
15:29some really great analogies.
15:31I really love the shopping mall,
15:33one that carried through
15:34the previous session,
15:36but I'm going to start with 1-2 and
15:38if we could go to the next slide,
15:42Digital health solutions
15:43are not separate services,
15:44but they're rather tools for.
15:47Healthcare providers.
15:48So when a patient can't access
15:51broadband or technology or make
15:54use of these digital solutions,
15:57we're actually removing a
15:58powerful tool from the toolbox.
16:01So Can you imagine removing a stethoscope
16:04or an otoscope from the toolbox?
16:07We we can't write those tools are
16:10essential for care delivery and
16:12just like that making sure patients
16:14are able to access and understand.
16:16Mobile health apps,
16:18patient portals and telehealth,
16:20all of that is equally essential
16:22as a tool for healthcare delivery.
16:25Next slide,
16:27I'm going to spend some time
16:29discussing how we can ensure
16:31that that toolbox stays full.
16:33And I'll share with you 10
16:35strategies that can help improve
16:36digital HealthEquity and hopefully
16:38we'll be able to build on the
16:41examples that Jorge just.
16:42Shared,
16:42but I'll I'll include system level
16:45strategies that can help all the
16:47patients that you're serving as
16:49well as patient driven strategies
16:51that can be personalized for
16:54individual patients and communities.
16:56Let's get started. Next slide.
17:00At a system level healthcare providers and
17:03technology companies can commit to designing
17:06and implementing strategies in a way that
17:08all patients can access and understand.
17:11In addition, they should be committing to
17:14including Digital HealthEquity as part of the
17:17conversation not only in the design phase,
17:20but also in implementation
17:22and evaluation phases.
17:24I'll give one example here on Common
17:27Spirit has embedded HealthEquity and
17:29Digital HealthEquity into their strategy.
17:32So they actually include questions
17:34related to technology access and digital
17:37health literacy in the process that's
17:39designed to evaluate digital solutions.
17:42They then go beyond this to evaluate
17:44the use of technologies and I'll
17:46explain how in a few minutes.
17:49Next slide.
17:51In addition,
17:52another system level approach is to create a
17:55process that engages diverse patient voices.
17:58And that can include partnering with
18:01community based organizations that know
18:03the needs of your patients and communities.
18:05It can also include creating avenues
18:08for underrepresented patients,
18:10communities and providers to give
18:12feedback on whether digital solutions are
18:16actually accessible and understandable
18:18by your real patients and communities.
18:22One example that I've included here
18:23on the slide is that hospitals could
18:26engage moms with low health literacy.
18:28To understand their communication
18:30preferences and tailor services to meet
18:33their needs and build their trust during
18:36this important time of their life.
18:38Next slide,
18:40another system level solution is
18:43tracking patient engagement with
18:45digital tools to understand the
18:47patients and populations that are
18:49actually using these tools.
18:51So let's go back to the example
18:53I gave from Common Spirit.
18:55Common Spirit has implemented Docent Health.
18:58A program to provide culturally
19:01competent navigators to pregnant moms.
19:03These navigators are embedded in the
19:06communities that they're serving,
19:08and Common Spirit has analyzed the
19:11data around the use of this program.
19:14And then they take that data and
19:15they stratify it by race, ethnicity,
19:17and social vulnerability to determine
19:20which communities are actually
19:22engaging in docent health.
19:24So by doing this data analysis,
19:26they quickly knew who was using
19:28the solution and who wasn't.
19:30They were also able to identify
19:32that for some Spanish speaking
19:34populations in California,
19:36providing a Spanish speaking
19:38navigator wasn't enough.
19:40They actually had to provide a navigator
19:43that spoke the right dialect of
19:46Spanish for their particular community.
19:49Next slide.
19:50The last system level strategy
19:52that I'll share today is advocacy
19:54and Jorge touched on this,
19:56but it is important for all of us to
19:58be advocating for policies that allow
20:01patients to access digital health solutions.
20:04So in addition to what Jorge said,
20:06my former employer,
20:08the American Hospital Association,
20:10is currently advocating for
20:12investments in infrastructure.
20:14And that includes broadband access
20:16as well as increased federal funding
20:19coverage and reimbursement for
20:21the expanded use of telehealth and
20:24other technologies.
20:25So if you're looking at what advocacy
20:28can look like for your organization,
20:30you could join those efforts or address
20:33specific policy issues that are
20:36happening at your local or state level.
20:38Next slide,
20:39now I will move on to some patient
20:43driven strategies.
20:44One way to improve digital health
20:47access for individuals is to provide
20:50patients and physicians with technology.
20:52So here I provide an example from the
20:55University of Mississippi Medical Center.
20:57They launched a pilot
20:59program several years ago.
21:01It was a diabetes telehealth network
21:04and it provided patients that
21:06were participating in the program
21:08with tablet computers at no cost.
21:10Patients were then able to take and
21:12report their own vital signs daily,
21:14which led to improved patient outcomes,
21:17increased medication management and
21:19the patients were more willing to
21:21participate in telehealth visits.
21:23So I will note here that there are
21:26many federal and state laws that apply
21:28to giving technology to patients.
21:30So if this is a solution you
21:32are looking to pursue,
21:33I do strongly recommend that
21:35you consult with your legal team
21:38before providing any iPads or
21:40other technology to your patients.
21:42Next slide Healthcare providers can
21:46also proactively work with technology
21:48companies to select solutions
21:51that minimize barriers to access.
21:53So Boston Medical Center was
21:55seeking to find a solution provider
21:58that could remote provide remote
22:01patient monitoring solutions to
22:04improve postpartum hypertension.
22:06And they evaluated a number of different
22:09solutions and ultimately their team
22:12recognized that a majority of their
22:14patients had access to smartphones,
22:17but there was a divide in
22:19patient's ability to connect.
22:20So some patients didn't have a consistent.
22:23Consistent access to Wi-Fi or they
22:25didn't have a data plan that could
22:28be used to support a video framework.
22:31So as a result,
22:32Boston Medical Center selected
22:34a provider called Remedy that
22:36uses the local cellular network.
22:38And it has made the solution acceptable
22:40to not only those that have Wi-Fi,
22:43but anyone who has access to a smartphone.
22:47And healthcare providers and
22:48technology companies also sort
22:50of need to acknowledge that.
22:52Sometimes digital solutions are
22:54not the best path forward to
22:56meet patients where they are.
22:58One popular alternative is using
23:00text messages to provide information
23:03and an access point for patients to
23:06connect with healthcare providers.
23:08So we know people text, you know,
23:11check their text,
23:12and research indicates that 90% of
23:14text messages are read within 90
23:16seconds of when they are received.
23:19So texting can be a powerful way
23:21to reach patients with the right
23:24message at the right time.
23:26It can also be done in different languages
23:28and is relatively cost effective.
23:31It's also just a really nice
23:33interactive way to triage patient needs,
23:35provide timely information,
23:37and improve communication and
23:40engagement with patients.
23:42I'll also note here that there are
23:44privacy and other laws to consider
23:46with texting.
23:46So once again,
23:47engage your legal team if this is
23:50an approach that you'd like to take
23:53as you move forward. Next slide.
23:57Another strategy is to develop digital
24:00solutions that are linguistically and
24:02culturally sensitive and inclusive.
24:04So Providence uses Wildflower.
24:07Which provides information and resources
24:10to patients from pregnancy through delivery.
24:14And as we spoke with the individuals
24:16who helped design this solution,
24:18they realized quickly that they
24:20couldn't just change the language
24:22from English to Spanish to be able
24:24to adequately meet the needs of
24:26their Spanish speaking population.
24:28They actually needed to
24:29evaluate the functionality of
24:31the app and ask the question,
24:33how would a Spanish speaking
24:36individual approach this app?
24:38And as a result,
24:39they created a solution that considered
24:42those individuals cultures as well as how,
24:45when and where they would be
24:47using the app Next Slide.
24:51These solutions can also be
24:53tailored to meet the needs of
24:55those with lower digital literacy,
24:57so for example by using more videos,
25:00images, emojis and symbols.
25:02Providers can ensure patients,
25:05regardless of their literacy level,
25:07are able to access and understand
25:10the information next line.
25:13In addition,
25:14those with low digital literacy may
25:17also be afraid to use technology
25:19or to trust their providers.
25:21So to address these concerns,
25:24healthcare providers can offer
25:25training and offer to support their
25:28patients throughout the process.
25:30One example,
25:31Oschner Health launched an OBAR
25:34many years ago and that OBAR
25:37carries physician recommended
25:38digital products and is staffed by
25:41a full time technology specialist
25:43that can help patients choose the
25:45right tool and also can help set
25:47up and guide and support these
25:50individuals as they use those tools.
25:53Similar to the example Jorge
25:55shared during the pandemic,
25:57Nemours Children's Hospital
25:58redeployed staff as digital health
26:02navigators to help patients and their
26:04families complete digital forms,
26:06troubleshoot connectivity issues and
26:09better engaged in telehealth visits.
26:12And then the last strategy is just that
26:16organizations can develop workflows
26:18that better allow clinical teams
26:20to engage patients in these tools.
26:23So Freighter,
26:25next slide please.
26:27Freighter and the Medical College of
26:30Wisconsin have implemented baby scripts,
26:32which is a platform designed to.
26:35Connect expectant mothers with
26:37their doctors and resources to
26:39improve perinatal outcomes.
26:40So expectant mothers are invited
26:42to join baby scripts after it's
26:45determined that they are pregnant.
26:47However, early on in the implementation,
26:49Freighter realized that certain
26:51communities and populations
26:53were not engaging with the app,
26:55so they created a process where
26:58their team proactively reaches out
27:00to those individuals who didn't
27:02accept the initial invitation.
27:04And encourages them to join
27:07and use the baby scripts tool.
27:10So I know I went through all of that quickly,
27:12but I hope those 10 strategies and
27:14the examples provided are helpful
27:16to you and your team as you take
27:19on Digital HealthEquity and Tara.
27:20I'll turn it over to you.
27:25Great. Thank you.
27:26I am enjoying this virtual symposium so much.
27:29I love all the tangible
27:31approaches and examples.
27:32I've been taking notes from my Co
27:35panelists and I really hope that I
27:37can build on what's been said so
27:40far in terms of digital equity and
27:42inclusion in regards to a specific
27:44very vulnerable patient population
27:46which is Medicaid beneficiaries.
27:48So that's where we're going to go in
27:50the final part of our segment here and.
27:54Basically, I'll start off with just
27:57explaining how Medicaid beneficiaries
27:58tend to access digital health tools
28:00now and as well as telehealth.
28:02And then I'd like to end on some policy
28:06considerations for how to ensure
28:07access to care for this particular
28:09patient population and how which
28:12could help mitigate against to health
28:13disparities now and in the future.
28:15So with that next slide please.
28:18So I thought I'd start off
28:20just by quickly clarifying,
28:22you know the major government
28:24payers here with Medicaid,
28:25Medicare,
28:25the numbers of Americans that are
28:28under those different government
28:29safety Nets along with dual eligible.
28:32So Medicaid is our program for low
28:35income individuals and there's about 76
28:38million Americans on that whereas Medic.
28:40Medicare.
28:40Medicare is for older adults and
28:43then dual eligibles would be those
28:45who qualify for older adults on
28:47Medicare who also are low income,
28:49which is over 12 million Americans.
28:52And I now want to touch on a report
28:54that was just published by the
28:56Government Accountability Office,
28:58really looking at the experience among
29:00the States and how they were accessing
29:03telehealth specifically and access
29:04to care for a Medicaid population
29:07and what it was like pre pandemic.
29:11And you know starting in March before
29:13March 2020 and then what's happened
29:15over the past year until February 2021,
29:17but there was this incredible 15 times
29:21increase across these five states.
29:23So with the next slide,
29:25you'll see a sampling of these States
29:27and they went out of their way to choose
29:30states that represent a broad swath of
29:32our population in terms of the percent
29:34that are in rural areas have access to
29:38broadband and then variations among.
29:40Demographics such as age,
29:42income and education and that's
29:43why these states were selected.
29:45And and you could see that
29:47right before the pandemic,
29:49about 11% of Medicaid,
29:50I'll use Arizona as an example,
29:5311% of Medicaid beneficiaries
29:55were accessing telehealth,
29:57telehealth for one or more of
29:59their healthcare services.
30:00But then in the year then the
30:02pandemic started in March 2020 to
30:04February 2021 that shot up to 43.8.
30:07And then just apply that across
30:08the board to these other states.
30:10And this builds on what everyone
30:12has been talking about,
30:13this huge increase in telehealth utilization,
30:16but then thinking about it in regards
30:19to a specific very vulnerable
30:21population group and how they
30:23were able to access telehealth.
30:25So with that, I'll go on to the next slide.
30:30So as I mentioned,
30:32Medicaid does largely support.
30:34It does support those who
30:35qualify through means,
30:36so their their income thresholds
30:38are below a certain amount.
30:39But in relation to that,
30:41there's two subgroups,
30:42those who also have disabilities and as well
30:45as being low income and those who are older.
30:48And I point this out because
30:50there's specific healthcare needs
30:52depending on these other two groups.
30:54So often times behavior health coincides with
30:57those with disabilities and for older adults,
31:00longterm care is a is a big issue
31:02and Medicaid is the largest payer.
31:04For longterm care in America.
31:05So when we think about digital health tools
31:08and access to healthcare via telehealth,
31:10how that would apply in that setting and
31:13the next slide gets right to that point.
31:16Where right now every state has
31:18a version of a state waiver,
31:21a health, health,
31:23home and community based
31:24services where in this case,
31:26looking at an older population,
31:28they have the option to go into a
31:30nursing home to receive care or they
31:32could sign up to hopefully age in
31:34place and receive care in their home.
31:37Which would be longterm supports
31:38and services where they would
31:40have an aide come out and help
31:41them for a few hours a day.
31:42But what's happening is the
31:44demand far outweighs the supply.
31:45So across America,
31:47Medicaid eligible older adults are
31:51waiting on average of three years
31:53across basically the whole country
31:55with over 820 thousand Americans
31:57waiting to receive care in the home
32:00as instead of trying instead of
32:02going to an institutional setting
32:04And then if we could click the.
32:07Forward advance,
32:07there should be a pop up here and they just,
32:10I'm talking about Medicaid
32:12eligible older adults.
32:13But this has a real impact for our
32:15whole society in terms of how we're
32:17caring for an older population and
32:19just how we can use our digital health
32:21tools and also access to care via
32:23telehealth in the home to really help
32:26individuals age in place and support
32:28a goal that many Americans share.
32:31Next slide please.
32:33So this is happening a bit and incremental
32:37effects during the pandemic there,
32:40there was a addition of Appendix K
32:43to home and community based waivers
32:45that many states took advantage of and
32:47that's where they are really trying
32:49to digitize home and community based
32:51services to allow for more digital
32:53health tools in the home to allow
32:55virtual visits as opposed to in person.
32:57So that could be a way going
32:59forward that states are really
33:00playing with options available to
33:02them in these Medicaid waivers.
33:04And I just wanted to draw attention
33:06because that keeps coming up as a way
33:09that the Medicaid system is evolving
33:11in terms of adapting new tools.
33:13Next slide, please.
33:15So I've broken down what are my Co
33:17panelists and others have mentioned
33:19in terms of the digital divide in
33:21terms of three areas and looking
33:23at a Medicaid eligible population.
33:25And that is the,
33:27the, the range of providers
33:29and services that are covered
33:31under those who are on Medicaid.
33:33And then those technology barriers
33:35that both my Co panelists Jorge and
33:38Priya really mentioned in terms of what
33:40they are and ways to address them.
33:41And the one that I'm going to
33:43focus on quite a bit is the.
33:45The differences between access
33:48to telehealth when it's video,
33:50audio versus audio only and the
33:53impact that could have on a Medicaid
33:55eligible population and and relatedly
33:57a payment parity if you're if you
33:59have very limited means it makes
34:01a big difference in terms of how
34:03healthcare can be reimbursed.
34:04Payment parity would be the same
34:07amount of reimbursement for in
34:09person care as it would be for
34:11telehealth whereas coverage parity
34:13would mean that the service was.
34:15Covered or if it's not covered at all,
34:18and how would an individual with
34:20very limited means receive the care
34:22that they need and would like?
34:24Next slide please.
34:26So it's a build on an example
34:28of how access to telehealth.
34:31Was broken down by Medicaid beneficiaries.
34:33This is a nice way of showing what
34:36states were doing in different ways
34:38before the pandemic started and then
34:40during the public health emergency
34:42where you could see this incredible
34:44increase in access when it came comes
34:46to particular services that were
34:49being provided now via telehealth.
34:51And you know,
34:52for the most part behavior health has stayed.
34:54It was high and it's remained
34:56high and and then relatedly,
34:58the other things have seen a huge.
35:00Huge jump, particularly dental,
35:03occupational health,
35:04even longterm supports and services.
35:06So these were allowing everyone's
35:08comments like things that states
35:10really did modify for their Medicaid
35:13populations in terms of widening
35:15the numbers of providers and types
35:18of services available to them.
35:20Next slide.
35:21But what was nice though,
35:23is it was further broken out by
35:26Medicaid beneficiaries accessing
35:27these services with video audio
35:30care as opposed to just audio only.
35:32So if we can advance again,
35:36great, It might be one more advanced.
35:38Thank you. And one more, sorry animation.
35:42So then you'll see that the
35:44this graph divides audio only,
35:47which is the yellow part
35:49on top with visual audio,
35:52which is the blue part on the bottom and
35:55it breaks it down by race and ethnicity,
35:57income, education levels.
36:00And then you see that for the most part.
36:03Individuals that are white,
36:04we're much more likely to
36:05access telehealth via video,
36:07whereas those who have a Latino
36:10background were much more likely to
36:12access telehealth via audio only.
36:14So it was just a nice breakdown of thinking
36:17about if we do limit access to care in
36:19ways in which it needs to be only video,
36:22video, audio,
36:23how that impacts particular population,
36:25groups within this already very
36:28vulnerable Medicaid population.
36:30Next slide please.
36:33So I and then thirdly,
36:34I wanted to draw attention to there
36:36are other ways to enhance access to
36:39care outside of state legislation
36:41and governor executive action.
36:43And that's what individual Medicaid
36:45departments are doing in certain states.
36:47And I highlight two examples here
36:49with California and Ohio where
36:51California passed payment parity
36:53for audio only as an example of how
36:56they were trying to ensure care
36:58for their vulnerable population
37:00group and Ohio did just really.
37:03Expanded across the board a range
37:05of providers and services that could
37:07that would be eligible to receive
37:09care via telehealth or virtually.
37:11Next slide.
37:14So in my remaining time,
37:16I wanted to give two state examples and
37:18sort of wrap up here with how state,
37:20how states craft their legislation around
37:22virtual care makes a big difference.
37:25So in Arizona, it's a very detailed
37:27approach to how telehealth is
37:29defined and then there's a very
37:32specific audio only carve out.
37:34We're really only in situations
37:37where due to technology or other
37:40infrastructure limits would
37:41be considered appropriate.
37:43Next slide.
37:46So this has had real implications for
37:48access to audio only in the state of
37:51Arizona and and they created an Advisory
37:53Council which many states have done
37:56particularly monitor audio only care.
37:58And in Arizona this past January,
38:00this Advisory Council recommended to actually
38:02reduce the number of codes that would be
38:05eligible for audio only by nearly 2/3.
38:07So that's the change of what once existed
38:10and currently what's happening in Arizona.
38:12And then in contrast,
38:13if I could compare another state in
38:15the next slide which is Colorado's
38:18definition of telehealth,
38:20you you see that it's quite broad.
38:22It's really just any type of care
38:24that's delivered at a distance and I
38:26think there's no audio only carve out.
38:29And also by having such a broad
38:31definition of how telehealth is provided,
38:33it allows for emerging technologies
38:35that we may that haven't come about yet,
38:37they will be about soon that really enables.
38:43The law the law can to be much more
38:45flexible given what could be happening
38:46with technology and then it's and
38:48it's and it's a different way of
38:50showing how states their approaches
38:53has a big impact on access to care.
38:56Next slide.
38:58So this is going to bring up I think a
39:00lot of tie in well with a lot of the
39:03comments that pre MA but some really
39:04tangible examples for what's happening
39:07with different providers and these
39:09different platforms of of addressing
39:11these issues with barriers to care.
39:13But I think mainly what I would
39:14just like to touch on when we're
39:16thinking about if we require.
39:19Video, audio services or in person visits,
39:22how that impacts the individual's
39:24access to care if they are this
39:27vulnerable patient population group.
39:29And I did include at the bottom with
39:32the regulator that's coming up more to
39:34the forefront of these discussions,
39:36which is the Federal Trade Commission,
39:38which basically says it's the standard of
39:40care that matters, not how it's delivered.
39:44Next slide.
39:45So my final comments,
39:46I think I'm right about time is I
39:49just want to touch on what's been
39:51happening across the country when it
39:53comes to rural populations trying
39:54to access palliative care.
39:56And it really comes down to patients
39:58having to make really tough decisions
40:00between being able to remain in their
40:02home and have their pain managed as
40:04opposed to going to a more urban or
40:06tertiary center to receive palliative care.
40:08And this is an article that came out
40:11pre COVID and it showed the impact it had.
40:15By patients being able to access
40:17palliative care in their home.
40:19And if we could touch on the next slide,
40:22our next, yeah, great.
40:23What a huge equity issue it was just to
40:25allow patients to have that decision.
40:27And I love how Jorge ended his slides
40:30with how how digital equity just
40:32helps us get to equity in general
40:35when accessing healthcare.
40:37And with that,
40:37I'll turn it over to our moderator, Dr.
40:39Krupinski.
40:41Awesome. And thanks all of you for
40:43such wonderful information for
40:45staying awesomely on time as well.
40:47So we have about 5 minutes
40:48for discussion in Q&amp;A.
40:49And So what I'm going to do is I'm going
40:52to throw a question out there and and,
40:55you know, put you on the spot.
40:57So you've all given some
40:59really great examples.
41:00And unfortunately, sometimes when
41:02people talk about HealthEquity,
41:04they can think, well,
41:05the system's going to take care of it.
41:08You know, so it's noted $65 billion
41:09that the government is going to
41:11spend on digital HealthEquity,
41:13large hospital systems,
41:14Medicare, Medicaid,
41:15states that are addressing HealthEquity
41:17by you know throwing resources
41:19at it and examples that pre gave
41:21with in terms of you know people
41:23doing research studies and so on.
41:25So the question that I have for
41:27each one of you and you can either
41:29volunteer or I'll start to point
41:31people out nobody answers is what
41:34can the individual practitioner.
41:37Sitting there faced with the prospect
41:40of a patient and then trying to decide,
41:43you know,
41:43how do I interact with this patient best
41:46given whether they know or don't know about,
41:48you know,
41:49where this patient is and so on.
41:50What can that individual practitioner
41:53do on their own to start to
41:57utilize telehealth to address
41:59health disparities or vice versa,
42:01to somehow look at the lens of telehealth
42:03and how they're going to do it?
42:06Through that lens of health
42:09disparities and HealthEquity.
42:11So I'm going to start with Jorge.
42:13I'm just going to go down the line.
42:14What do you think the one one
42:16thing that a practitioner could do?
42:18Yeah,
42:19I mean, I think that the simplest
42:20one for me is it seems simple,
42:22but it's like talk, talk to the patient.
42:24I think having that conversation and that
42:27we learned that with our Digital Navigator.
42:29Having that conversation,
42:29like what's the pain point that
42:31you're feeling and how and is there
42:33a technology that can address it.
42:34You know, I think sometimes we
42:35try to think of technology very
42:37broadly and like we can do this,
42:38we can do this, we can do this.
42:40But for the individual patient it
42:41may be like I'm really struggling
42:43for I don't know and if we've tried.
42:45The framework of all of this with like,
42:47with how the health and equity in
42:49mind increasingly we're moving toward
42:51structural and so terms of health.
42:52So using that as a starting point as
42:54like what what Which one of those is
42:56being challenged and how can tech.
42:58Bridget,
42:58if it's like I'm struggling with
43:00housing insecurity and you're like,
43:02well, technology is not really
43:03going to make a difference there,
43:04then perhaps technology is not
43:06the right solution.
43:06But it's like oh, you know,
43:07I'm really struggling with like,
43:09you know,
43:09getting access to care getting
43:10time off from work or something.
43:11Oh, OK well,
43:12telehealth can play a role there.
43:13Let's try to make it use,
43:14I think talking to the patient.
43:15And seeing how it in lines
43:17with HealthEquity frameworks,
43:18I think it's where I would start.
43:19Great
43:20answer Priya. So Jorge stole my
43:23answer because they ask the patient,
43:26right, which I think is an excellent
43:29sort of place to start is in
43:31conversation with the patients about
43:32what they actually want, right.
43:34So I often use the example of my parents,
43:36they are both in their late 70s, my mom.
43:39Hates technology.
43:40She wants an in person visit all the time.
43:43She enjoys the communication
43:45and the conversation.
43:46My dad on the other hand is very tech savvy,
43:49even more so than I am,
43:51and he wants everything done
43:52through an app or portal, right?
43:54So asking those questions and.
43:56Not making assumptions and I think
43:59Jorge made this point earlier
44:01as well as to who may want a
44:03digital solution and who may not
44:05asking that question of everyone.
44:07And then I will say one of the
44:09challenges when I was working at the
44:11AHA that we heard consistently from
44:13clinicians was that they didn't always,
44:15once they asked the questions,
44:17they didn't always have the resources
44:20they needed to support the response
44:22that an individual may have.
44:24So I think doing some work on.
44:26The back end to make sure that
44:28some resources are available for
44:29different responses that you may
44:31get and if you are a clinician,
44:33sort of employed by a hospital
44:35or health system asking for help
44:36in getting those resources.
44:38So I took Jorges and then built
44:40a little bit on it. Awesome.
44:42Sharon. Yeah, 60 seconds.
44:45Likewise I. What my Co panelist
44:47said and then just to make it,
44:49make it embedded in the system.
44:51So when you have that
44:52first point of engagement,
44:54you know there's those preferred questions.
44:55How would, how would you prefer
44:57to receive this information?
44:57How would you prefer to have
44:59your visit conducted and and then
45:01let people choose between text,
45:02e-mail, audio only visual.
45:04And so for every patient
45:06regardless of their payer,
45:07Medicare and Medicaid private out of pocket,
45:10like you know their preferences
45:11upfront and you're treating your
45:13patients equally across the board.
45:16Right, awesome. And so thanks all of you.
45:18I have one other thing to add would be that,
45:20you know we have to educate patients
45:22as to what these terms mean because
45:24I've heard so many stories about, well,
45:26I picked the virtual option or I I picked
45:28the telehealth and then they get there and
45:30they don't realize what they picked and they,
45:32oh, I picked telehealth.
45:34I didn't realize that meant I
45:35had to connect up.
45:36So even though people can go through
45:38that checklist and and pick things,
45:39it's not just a matter of.
45:41You know, do they have the access
45:42is do they have an understanding
45:44of what these options are?
45:45And that's where things like videos,
45:47you can send them in advance or
45:49whatever explaining, you know,
45:50what is telehealth all about.
45:51So I appreciate your time, your effort.
45:54I think it's been a wonderful
45:56presentation and hopefully everybody
45:58learned a little bit about ways
46:00to address digital HealthEquity.
46:03And Lee, I'm turning it back over to you.