"Our challenge now is using the data correctly to generate actionable evidence and insights"

Q: Tell us a bit about the MUSC, the population you serve, and your role and responsibilities there. What kinds of programs do you run?

David: The MUSC is an academic medical center in Charleston, South Carolina. We have five campuses throughout South Carolina and serve the entire state. In addition, there are six different colleges, a diverse student body across health professions and disciplines, as well as great research infrastructure. These have contributed to and driven innovation. As the CMIO at the MUSC, I look at the integration of technology especially in clinical care — and how that impacts the workflow of physicians and other care team members — and patient experience and focus on such integration across different types of technology to streamline the practice of care.

Q: How did you codify some of this knowledge, learning and best practices into something that your peers across the country could utilize?

David: Our Centers for Excellence have produced a number of instructional documents and resources on how to implement telehealth best practices, both, from clinical and operational standpoints. We’ve done a lot of work in the spaces of education and training. In fact, several years ago, we opened a state-of-the-art Center, the Telehealth Learning Commons in our main campus through which we’ve hosted different clinicians, administrators, operational personnel and policy makers from across the country to demonstrate the value of telehealth. That space is also used to conduct classes. But all this was largely pre-pandemic, of course. We have, however, expanded on how we approach interdisciplinary education in terms of developing competencies for telehealth across different disciplines and preparing our workforce of the future to be engaged in telehealth as they go out into their chosen professions.

Q: If one of your peers across the country wants to access some of these materials or programs, where should they go?

David: Our website for the Center for Excellence at MUSC.edu is a good resource and to access profiles, there are Twitter and LinkedIn as well.

Q: The meaning of “telehealth” varies — depending on who one talks to, and may be based on demographic profiles, geographies and the type of care being delivered – as widely as the application of telehealth programs and technologies. Can you help us understand telehealth and how best to implement these programs?

David: Well, the key really is to focus on the problem one’s trying to solve rather than the technology. There’s a variety of technology available and the emerging technologies advance what we’re capable of. So, you don’t want to walk around with your hammer looking for a nail. You want to really focus in on the requirements and the gaps. Once you define what it is that you need to do — how to improve patient care, enhance workflow of your providers, coordinate care across settings or across institutions and across locations – and identify the challenges to be addressed, then, the tools will present themselves. These may span a synchronous video consultation, physician-to-physician, physician-to-patient, an asynchronous encounter, remote patient monitoring — there’re so many different tools that it can be a little overwhelming. But the best way to focus in on that approach is to start with that problem.

Q: With regard to synchronous video conferencing or even a phone call and a number of other things, isn’t telehealth just that?

David: That’s actually a really key point, especially now in the pandemic. As we emerge from it, and it gets to the issue of health — of equity and disparities in access to care — some of the research we’ve been doing actually demonstrates that those at a socioeconomic disadvantage, or with pre-existing disparities in access to care, use telehealth as a broad term at the same rate, or that utilization has increased similarly, across those groups. If we look at the distribution of whether it’s video telehealth or audio telehealth, those who are coming from disadvantaged backgrounds or from other areas that don’t have the same access to technology, seem to be disproportionately using audio telehealth. And that’s really important because as we emerge from the pandemic, looking at the ongoing policy debates and the regulations enacted during the public health emergency as they begin to expire or be rolled back, if the reimbursement for audio-only telehealth is peeled back more so than reimbursement for video telehealth, suddenly we’re only actually exacerbating the disparities. And that’s something that must be maintained and focused on.

Q: What are some of the challenges you’ve faced in rolling out a telehealth program?

David: One of the big challenges is access to broadband and it’s been very apparent during the pandemic. Broadband is something many of us take for granted but in rural areas, people may not have access to it. Another important consideration is when you have access to Broadband, whether you can afford to pay for the data that it takes to do a telemedicine consult. Those may be two completely different things. And so, you need to take that into account as you’re rolling these programs out. The other really important lesson learned is to focus on usability both, for the patients and the providers. The first telemedicine program that I developed was a pediatric critical care telemedicine program that provided emergent consultation to rural community emergency departments for critically ill and injured kids that came into those facilities. In such situations, it’s incredibly important for the system to be as easy to use as possible in that rural or community emergency department, because often they’ll have a very chaotic or very least-very high stress situation, on and logging into your system shouldn’t be worrying. You want to just roll the cart into the room and make that connection. That’s how we develop that program and it was one of the really key aspects of that program’s success.

Q: You’ve been involved in some very interesting work on pediatric research — the SPROUT Program. Please elaborate on this.

David: SPROUT is really the nation’s first national collaborative telehealth research program across both, adult or pediatric services. The SPROUT Network was formed because of the recognition that advancing quality telehealth services really requires having the evidence and data to support what it means to provide quality health services. If you really want to influence adoption of telehealth at the physician level, physicians have always been raised on the concept of evidence-based medicine. If that evidence’s missing, it doesn’t matter that the telehealth program sounds like a terrific idea. They need to know that when they’re going to be taking care of their patient, when it’s a change in practice to the way they interact with their patient, that the evidence is there to support it. SPROUT, stands for Supporting Pediatric Research on Outcomes and Utilization of Telehealth, was formed with several very talented folk from across the country who came together and developed the first National Pediatric Telehealth Infrastructure Survey. We collected data from across the country and developed a collaborative of over 140 institutions across the country and in some other countries that develop frameworks and best practices and provide education around how to study telehealth in your particular institution. We got NIH funding back in 2019 for the program through the National Center for Advancing Translational Science. And we’re just getting into the third year of that funding. Obviously as we went into the pandemic, all of our work became critical to the way that telehealth was being practiced, especially in pediatrics nation-wide.

Q: Given the program is now 2 years old with ample data, could you share one or two findings that may be worthy of consideration?

David: One of the things we did very early on during the pandemic was we brought together national webinars to explore how people were utilizing telehealth in the pediatric setting and studied the challenges they experienced. We identified very early on, the challenge for non-English speaking populations in terms of access to telehealth. Now, the majority of telehealth platforms have been designed with the assumption the patients speak English and that bringing in a translator into a telehealth interaction can be difficult. The platforms themselves often are not available in anything other than English. And that was something, as telehealth programs scaled out across the country very rapidly during the early days of the pandemic, that a lot of institutions were really not prepared to address. Thus, SPROUT served as a convener to bring people together and identify best practices to how to approach that and serve as broad a population as possible. We’ve also done a lot of evaluation around how different institutions and different practices have responded to the pandemic and are working on getting published some data on educational approaches to scaling out telehealth services. We’re also working on publishing a policy evaluation stakeholder table or framework that allows one to evaluate programs based on the different stakeholders that may be engaged in moving a program forward. That may be a hospital system, a patient, a provider or even, a policy maker. We really have a very broad array of tools that we’re developing and they’re really coming out.

Q: Telehealth and the pediatric context is a very interesting space because it’s not just about the minor patient but about the parent, too. Sometimes, both entities may be in different locations and there’s the translator in the middle which can be confusing. But doesn’t this also apply to adult care? Will telehealth platform providers introduce the capability to have a translator in the mix every time there is a video conference call?

David: A lot of people in the industry and vendors have been focusing on this in the last year. Some really creative approaches have now been rolled out. Obviously, multi-party calling is a big part of that — just being able to bring an interpreter into the virtual room when needed, ensuring that the platforms themselves, the education provided there and the instructions are multilingual. Some of the really exciting stuff though involves technologies such as, natural language processing, real-time interpretation and the use of voice recognition — the kind of tools that, when we look back 10 years from now, will reveal how the pandemic really shifted the evolution of telehealth and digitally-enabled health care, in general. The integration of these emerging and promising new technologies into a unified approach addressing those with chronic disease and some of the most challenging patient populations around is possibly where the shift really happened this past year.

Q: Natural language processing, voice recognition, chatbots, Google Glass enabled services – are all based on natural language interfaces. As the CMIO, how do you view the data from these platforms and interactions? How do you harness data streams to generate insights that can improve outcomes of productivity and the quality of the experience?

David: This is one of the key issues that needs focus once we come out of the pandemic especially if we’re to stay focused on the telehealth aspect of things. There’s been such an explosion and adoption of telehealth that our previous challenges around not having enough data is really a thing of the past. Our challenge now is to use the data correctly to generate actionable evidence and insight into what is the best practice. How do you coordinate this across different practices and technologies? How do you develop that hybrid approach to providing either in-person or virtual care by a number of different modalities and do so in a way that is streamlined, that fits into the workflow of clinicians and other providers, and that supports the operations of the hospital in an effective way? Looking at this massive trove of data we have now, one of the things that SPROUT has done is develop a telehealth evaluation and measurement framework that helps folk make sense of all the data coming in. Look at it from the standpoint of a particular program, at a particular stage of maturity, from a particular stakeholder’s viewpoint and the population that’s being served. How do you pull the most meaningful data in the most generalizable information out of the data you’re getting for this service to really advance that safe and effective telehealth service going forward?

Q: What are some of the biggest challenges when you’re going beyond your core electronic health system and trying to tap into innovative new technology solutions? How do you address the integration of different platforms with the main electronic system and more importantly, ensure cybersecurity?

David: People get tired of the term governance, but that’s what’s incredibly important and really generating the alignment. These different technologies often emerge and become central to everything we do in the health care system. Consequently, it’s hard to identify a technology that only impacts one area. There will be overlaps and duplicative capabilities of different platforms. So, there will be platforms that are already in place to do the things for which people are looking at newer platforms. Then it’s important to understand — what your current capabilities are, what is the real gap in what you can do, and how the technology that you have could address those gaps versus what new technology you may need to invest in to be able to effectively address those gaps. That’s a real challenge because, in a health care system — particularly an academic system that has research, education and clinical components — there is a revenue cycle and operational issues and these platforms can be highly integrated. They also cross over into so many different areas that it’s hard to have a good understanding of how your platform and technology decisions impact all the different areas of the institution. Gaining that alignment and that shared decision-making and having that governance in place, is incredibly important.

Coming to the second question, a few months ago, I would have said cybersecurity is an under-recognized risk. But today, I feel like it’s not really recognized anymore. While we have major health care systems now that are being forced back to paper for weeks at a time because of prohibitive ransomware attacks, you have to invest proactively in your cybersecurity. While doing this, you also have to be very proactive in how you engage your cybersecurity team to ensure that they can identify where the risks actually lie. We’re long past the days when a platform could be evaluated based on a clinical need and then handed to the security team to ensure proper fit. The security team must be engaged early on in the process to ensure that you’re not exposing risks that you may not have even recognized were there.

Q: We’re coming to the end of our program now. But there’s one aspect yet to be touched upon. How does one ensure that providers and caregivers can enhance the delivery of care, stay productive and not burnout with the new technologies?

David: I think it’s incredibly important and we all know by now that provider burnout is real. The emergence of technology had and still retains promise, but the ways in which it has, at times, been implemented, has exacerbated challenges and increased workloads on our providers. Organizations like the ONC have taken steps to streamline the electronic health records and there’s some progress there. But increased focus in the health care industry, currently, is on consumerism. There’s certainly a lot of value in that. While there may be some patients that we shouldn’t really think of as consumers because they don’t have those consumer-type choices when they have the significant chronic or complex diseases, still, I see the value in the consumer-focused approach. However, one thing often overlooked when discussing digital health and technology, is that the providers are consumers, too. When it’s a new technology being adopted, especially one that sits in the interface between the doctor and the patient or the nurse and the patient, then there are two sides to that interaction and both are the consumer. When one’s designing, implementing technology or training and supporting it, one must think of the providers, physicians, one’s care team members as one’s customers, because really that’s how they function. If that mindset can be developed around both sides of the equation, then, one can really make a lot of progress in making the experience better for everyone.