"If telehealth is our first peak of digital medicine in COVID, the second will be digital monitoring."

Ashish Atreja, MD, MPH, Chief Innovation Officer, Medicine, Mount Sinai Health System in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “If telehealth is our first peak of digital medicine in COVID, the second will be digital monitoring.”

PP: Hello again, everyone, and welcome back to my podcast. This is a Paddy, and it is my great privilege and honor to introduce my special guest today, Dr. Ashish Atreja, Chief Innovation Officer of Mount Sinai Health System in New York. Ashish, can you share a little bit about your role at Mount Sinai and what you are working on today?

AA: Currently, I’m the Chief Innovation Officer in Medicine at Mount Sinai Health System. My goal is to really enable digital health together for value-based healthcare and healthcare efficiency. My foundation was laid in Cleveland Clinic where I did my Residency and Informatics Fellowship. I led on to implement an electronic health record for the hospital. And that got me to innovation bandwagon where I got a chance to go to the first web-based paging application way back in 2006. Really good to see the value in being licensed out and implemented across the clinic health system. And then Sinai hired me for a role where we can combine the best of digital health with the electronic health record to make it a wholesome, patient-centered experience for healthcare. So, it has been just a fascinating journey, learning from everyone in the community, from startups to my partners in NODE.Health and trying to make a difference.

PP: Can you tell us what NOAD.Health is about?

AA: One of the major gaps we see in our ecosystem is there is so much going on in digital health. But who puts it together in terms of saying, these are the best solutions that we have to look for? But really taking a scientific approach to that. So, we created this concept of evidence-based digital medicine or EMDM where we can trust really what is working, what is not working. We create a framework for people to evaluate the technologies because then we feel comfortable in advising and bringing them to the health systems. NODE.Health is a nonprofit network of societies, foundations, and health system associations. It is followed by a consortium of health system leaders and the goal is to first promote evidence for digital health and then enable transformation. We do that through our validation network we have. We also do that through annual conference we have as an education way for people to learn from the case studies and learn from each other.

PP: In my work with health systems today, we see that digital transformation is accelerating and largely as a result of competitive pressures. It seems to me that the focus is primarily today on telehealth and digital consumer engagement. Obviously, because of the high revenue dollars attached to improving access to care. Is that a fair observation? Can you talk of some of Sinai’s digital investments in the near-term and from the longer term as a consequence of the pandemic?

AA: With the COVID phase, COVID has been the biggest transformation agent for us, I would say the progress we saw which would take a few years happened in months. But I think the COVID phase is actually parallel. The transformation technology that has been happening, the access was a big issue and initially, we got it to rise because of the bots. The bots happened to screen patients because we did not have much triage capacity with our personal thing. But then because we had to convert rapidly our in-person visits to video visits, telehealth really become mainstream. I think consumer engagement telehealth became mainstream because of we could not see in person. Post-COVID or the tail of the COVID will take us to a world that is going to persist. If telehealth is our first peak of digital medicine in COVID, I feel the second peak is going to be digital monitoring. Nearly every patient can be monitored through a software or a hardware that will dovetail into a population health approach. That is where I see the biggest gain as well happening from the technologies.

PP: How are the consumers responding to the shift towards telehealth? Are you seeing not just the volumes showing an uptick because that is to be expected, but also the kind of satisfaction levels? Are they happy with the experience, are they going to stay with it when things come back to normal?

AA: My wife is practicing cardiology and she was saying all my patients are coming back as a re-open for the physical thing. And we are going to see a variable pattern. I call it a blended approach. You are going to see some patients who have tasted telemedicine and may not require that heavy physical examination or heavy touch, maybe completely ok with preferring telemedicine. Some people would be equivalent. And some people would still like to come in. I think where it becomes really tougher is now the practice, patients who tasted telemedicine will demand a mixed approach. Some patients will lean towards telemedicine continuation and some will actually go to physical. So, you have to actually take all of those aspects into account. So, it creates an additional layer of complexity than telemedicine only.

PP: In this whole new world, there’s a lot of startup activities that are trying to address opportunities with digital engagement touchpoints in this new virtual care environment. How do you see them holding up from your standpoint? Do you see them pivoting their businesses? Are they staying the course? Are they doing something different? You have a unique perspective by virtue of being the Chief Information Officer. Can you share your observations on that?

AA: I think there are many startups who are suffering if they are in a unique niche area and they are in a research skill or something. And your entire business model was dependent on that. You certainly are in a no man’s zone and don’t know where to go. I have seen many startups evolve and rapidly kind of support virtual care. I can give examples for the Mount Sinai spinout Rx.Health, which I continue to guide. And they have a platform approach to prescribe digital medicine directly from EHR and unify the entire ecosystem. They rapidly extended a partnership and got a whole virtual care tool kit with national societies to support health systems. I think startups, which already have the ecosystem and the infrastructure and the platform, like in case of Rx.Health, it was just adding additional tools to it, will rapidly able to do that and evolve themselves. And that is like one million lives within three months. And startups who are very early are startups who have a unique niche area were struggling. So, we are seeing both patterns, but irrespective we are seeing a pattern where consumer engagement and more than AI engagement really has become pivotal. And patients are able to see what a health system, what a good patient engagement looks like.

PP: In the wake of COVID-19, startups, by definition, they’re meant to be opportunistic. They’re nothing if not opportunistic. One thing that we are seeing is that there’s a lot of emerging opportunity in addressing the immediate needs of the COVID-19 pandemic. And it is a lot of apps, a lot of new solutions, and a lot of existing platforms. They have now either built or launched “COVID-19 applications.” I read a study recently, I think it was done by the University of Illinois in Urbana Champagne, which looked at some 50 different apps, and they raised a lot of questions about the evidence of the effectiveness of some of these tools. They also raise questions about things like the privacy of the consumer data that they are going to access. What do you make of all those that you, as the Chief Information Officer, especially in the NODE.Health? How do you really adjust to all of this? I mean, make recommendations about what tools are going to work and what will not?

AA: I think in terms of COVID, it’s tougher because we don’t have a legacy or a history. We don’t have the time to evaluate. So here you will have to really just see what is happening in real-time and just make some conclusions out of that, which can sometimes be wrong. So, I can take the example of contact tracing apps, which I have been engaged with a lot. And it is just a no-man land right now. This is not like South Korea or China or in some cases India, where you have a government-mandated app that everybody is using. This is free for all and there are so many apps in the market. Most of them are not talking to each other. So, what is the value in terms of public health? There can be value in personal health by guiding. But what is the valid public health space is uncertain. I think what you also have to take into account that you do not have the luxury of evaluating everything. When it comes from a health system perspective my recommendation will be, we look at patterns, look at problem first approach later than what’s out there as a shiny object syndrome. COVID has also accentuated the problem of shiny object syndrome. I think we have to say where your health system is really struggling with. Is it getting new patients into telehealth? Is it as you are reopening getting patients back into surgeries or appointments? Is it your ACO population that is really getting hospitalized a lot? Is it post-discharge care where you are struggling? Or all of that? And then which are other solutions which actually fit into that our platform solutions, which can serve all of them. My recommendation would be to not go with one isolated partner like a point and get solutions. But look at COVID solution as a strategy to evolve post-COVID. So, take the solution that you would really like to evolve and play with post-COVID because it is so much time in security as has been integration and of diligence and other staff. You want to leverage it for the long term, not just for the next six-nine months or so.

PP: Yeah, you mentioned contact tracing. That was the other thing that I was going to talk about. My firm’s been following this, and I’ve been following this. Google and Apple came together and launched the API but then ran into a few challenges because, you know, the public health agencies wanted location data, and they don’t want to share that. So, you know, there is questions about reapplication that wouldn’t be built on top of the API and how effective they’re going to be. Having said all that, despite all of the challenges, it seems to me like some of these new technologies, contact tracing, for instance, have a lot of potential in the future, regardless of whether it is to deal with COVID-19 as a concept, as a theme. Seems like there’s a lot of potential for that. And from my experience, it looks like some health systems are doing their own contact tracing within their own populations in a very limited way. Do think that’s the way to go right now, look at your own population, focus on that, and try to make it work, and then we’ll see about what happens in the broader scheme of things?

AA: I think its elementary. In fact, I’m working closely with MITRE, which is a nonprofit which works with federal agencies a lot, and the presentation was completely focused on we need to have a complementary approach for health systems and public health agencies. And I’m talking with the New Jersey Public Health in New York City as well. And if we just limit the stuff to contact tracing to public health agencies, they don’t have their own patients. So, they’re going to be just putting something out there, but that adoption can be very, very variable. I’ll take the example of Mount Sinai Health System, we launched an initiative called STOP COVID NYC. We were able to reach out to close to one million New Yorkers. Within a few weeks, and we were able to actually digitally monitor 55000 people. I think there’s a value in having five million patients in your network, which you can reach out to and get to engage with them and protect fifty-five thousand employees. So, there’s a lot at stake for health systems and for self-assured employers as well. I do think at least in the U.S. there is more federal approach and data sharing issues and privacy concern, we cannot wait for nine months to actually have a mainstream contact tracing app universally if at all that happens. We have to still look at and within weeks or within days, protect our population and patients.

PP: I think New York is a great example of public-private collaboration, especially in the wake of the COVID-19 crisis and New York is also one of the most heavily impacted areas in the country. Back to the patient experience, consumer experience when it comes to digital engagement. There is no dearth of digital health tools that can solve some problems in the entire patient care continuum, especially in the context of digital engagement. At the same time, I hear all my clients and everyone, they’re saying that they are struggling with creating the seamless experience that people look for and something that you might be used to in an Amazon type of experience or your personal banking experience, for instance. That kind of experience seems to be very, very challenging in healthcare. Why is that? Is that because apps do not talk to one another? Is it because we are not designing them properly? What are your thoughts on that?

AA: I think there are two potential reasons. One is the EHR. The APIs is now opening up. So if that’s your system of record and that’s where your physicians are living, the patients are completely living in a patient-centered world, you have to have an open API to share the data to actually enable that seamless thing. If you can’t have open API, even if it is said they have open APIs and it’s not easy to do that, then you can’t create a customized experience because your record is completely in a proprietary system and you are not able to unlock that. That has been the number one major stumbling block. With FHIR and other standards, I work in FHIR at the scaling committee for ONC FAST Committee, and I think they have in progress. But still daggered what is possible to what is actually a really feasible what people are doing. It like a O gap. The other part is there are differences in operations, whether it’s underserved or not, digital disparities, and also disease-specific differences. Getting a primary care doctor visit is very different than having a surgery done on new for orthopedics, for example, or getting a heart attack or being in a stroke or being in a nursing home. So, the context, the people around you are very different, the length of the time is very different. So, there is enough variability on the patient level, on the system level, on the electronic records level, to be able to orchestrate that in a meaningful fashion and make it universal requires time and effort and investment. And look at the investment Amazon has to make it a seamless thing, people undercount. They just see the expenses here. Hey, let me get it without investing 100 dollars per year and do it, while I am a five-billion-dollar health system. So, I think there is something to be said about investment, but also something to invest in investment, getting things together to make it unified in unison and rather more fragmented.

PP: We’ve had the final interoperability ruling come out in March. And leaving aside the information blocking aspects of it, when we talk about creating these seamless patient experiences, you think that’s going to make a difference? Do you see improvements coming about in the experience directly as a consequence of the ruling?

AA: Yeah, I think that we are going to see a lot more applications, patient-centric applications, leveraging that. And I think we have been waiting for that for a long time. But I think that would become much more mainstream now. There’ll be definitely value. I think the data exchange between EHR’s to EHR’s will still be less. But I think at least the patients will have it, hopefully, and then they can be a whole ecosystem that has to be developed around it.

PP: We’re now in the midst of COVID-19 or somewhere in the journey. But clearly, there is a shift to virtual care and virtual care models of have accelerated, telehealth is mainstream, digital front doors are all the rage, and remote monitoring is gathering steam. We did not talk much about the remote monitoring piece. Do you want to spend a couple of minutes talking about how that is going to change the healthcare experience in the future?

AA: Yeah, I think remote monitoring is probably going to become the dominant way to manage patients. And continuously manage patients. Whether its chronic disease and the reason I am saying that till date the remote mountain has been suffering from two things. One is hardware only play and the patients may not have an easy way to set it up and link to the Wi-Fi. But with 4G devices, which can actually implement hardware, we do not have anything to test or connect makes it very easy. The second was reimbursement for that. So that’s why there’s limited mostly to ACO or post discharge. Now with reimbursement coming from RPM and CCM codes. I think we’re going to see a lot more mainstream implementation of that. I think any chronic disease patient as cardiovascular to others will require digital monitoring. And we are doing it a lot for even many devices which do not have devices by doing software, only digital monitoring. And that is even much more affordable than the hardware on the disk monitoring where you can access patient symptoms and other things to track them and schedules and logic for them. So, I think this combination whether its value-based healthcare, whether it is the readmission reductions, whether it is payer, and then you can automatically set up triage rules or alerting rules to convert those people who are digitally being monitored and can load them into virtual visit or in-person meeting as needed, as we saw with COVID-19. I think we are going to see a lot more push on that and becoming things to scale and getting a lot of value for health systems to decrease the cost, increase efficiency, and improve outcomes.

PP: I think the reimbursement environment is definitely improving, as you mentioned. We saw that for telehealth they made some significant changes and those changes may possibly stay on for the longer term. And we see the same kind of positive momentum on the remote monitoring side as well. So, all that is good news for virtual care models. Well, Ashish it’s been such a pleasure speaking with you. And thank you so much for taking the time to join us and look forward to following all of your work at Sinai and Node.Health and of course, Rx.Health. Thank you again.

AA: It’s been a pleasure, Paddy. Thank you for having me.

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Disclaimer: This Q&A has been derived from the podcast transcript and has been edited for readability and clarity.