Digital health equity is an emerging gap in health [PODCAST]

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“The pandemic has demonstrated the value of online platforms, especially in health care – but equitable access has not matched this growth. Sadly, many Americans cannot reap the benefits of connectivity. State and federal funding sources are required to enable digital health equity. Moreover, there should be a focus on measuring/creating standards of care in digital health equity. Public financing and public infrastructure (broadband) will be essential to coordinate organizations and defragmenting care. Now is our moment to create a new and better health care system that emerges from the dark days of COVID-19.”

Joshua W. Elder is an emergency physician.

He shares his story and discusses the KevinMD article, “Digital health equity is an emerging gap in health.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Joshua Elder. He is an emergency medicine physician, and he co-wrote the KevinMD article together with Tammy Scott, and it’s titled “Digital health equity is an emerging gap in health.” Joshua, welcome to the show.

Joshua W. Elder: Thanks, Kevin. Thanks for having me here.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Joshua W. Elder: Yeah, I appreciate that, Kevin. My journey here has been, I think like many others, around finding my passion and my purpose. I started off channeling a passion in medicine when I was at Pitt as an undergrad, went to the West Coast for med school and residency, found a real interest in serving the community and in bringing access to the community for health, and became an emergency physician. I continued my path out on the East Coast to get additional training as a Robert Wood Johnson Clinical Scholar, where I began to really discover how health care and innovation really intersected.

Kevin Pho: As an emergency physician, can you give some case studies, examples of health equities that you see every day in the emergency room?

Joshua W. Elder: To me, it’s really around: Can we meet the need of a patient where they’re at, when they need it? Countless times, I think, as emergency physicians, we see gaps where the access that patients really require is just not there. Anything from patients arriving in the emergency department to get specialty access, patients coming into the emergency department to get lab access, patients coming to the emergency department to get their primary care, but even patients who have great insurance. Patients come to the emergency department just for access that is unparalleled, for all times of the day, all hours of the day, every day of the year.

And so, seeing that scope of health, you see diverse populations, and you see a wide array of things. It begins to give you insight around where some of the gaps exist and maybe what some of the solutions might be to help.

Kevin Pho: Over the last 18 to 19 months during the pandemic, how has that affected the health inequality that you’ve seen in the emergency department?

Joshua W. Elder: To me, it’s created an even greater chasm. Before, there used to be greater access points, and I see now the emergency department is one of the kind of remaining points, especially when COVID happened, where access still occurs. We’ve seen upticks in, obviously, substance use disorder and suicide and depression among adolescents, and really all populations, and we see upticks in that in the emergency department. The lack of preventative care, the lack of meeting people when they need that care, I think has resulted in a culmination of basically a great crisis in front of us.

Kevin Pho: And what’s the root cause for this lack of access? Is it simply a lack of clinicians? Is it insurance issues? What do you think are some of the root causes that bring people to the emergency department for primary and specialty care?

Joshua W. Elder: It’s a really, I think, complex question, but I think the simple answer is that health is a part of us, of just who we are as humans. And I think when we look at our political fabric, our economic fabric, our geographic fabric, we often don’t meet the needs of where patients are at. We don’t define health care as a right. We don’t provide just basic access and basic needs for the patients when they need them.

So I think what we see as a result is the emergency department becomes a reflection of our community, the things we’re doing both well, maybe regionalization of care and great trauma care and great stroke care, but we also see a great need emerge. And it’s hard to continue to see that need and not want to do something about it.

Kevin Pho: And we’ll talk more about those issues in the KevinMD article that you co-wrote with Tammy Scott. It’s titled “Digital health equity is an emerging gap in health.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Joshua W. Elder: Well, Kevin, this has been really a journey to this point. When I was on the East Coast and I started this interest in an intersection, you know, seven or eight years ago, it was in trying to figure out how we could provide access to specialty care for patients that really had Medicaid and were waiting about six months to get care. And so we created, in the Yale New Haven system, an integrated model with FQHCs to provide better access, whereby patients went from six months to about six days to wait for specialty consultation. That insight, I guess, provided a great awareness of how access can really be transformed through telemedicine, telehealth, and really, digital health is more of an umbrella term.

And as I came to UC Davis Health, I began to really want to create a product and system whereby that access could emerge for the patient when they needed it. And so over the past two and a half years, really, we’ve grown a system here where patients, now any Californian, can access care independent of payer status, independent of age, independent of where they are located, and can access one of our health professionals here, from a system that really started from a value proposition that access and equity for our patients is fundamental to being able to achieve many of the outcomes we strive for in our society, but also as providers.

Kevin Pho: So tell me about what exactly that looks like. If a patient wants primary or specialty care and doesn’t have any primary care clinician, what would that digital health solution look like?

Joshua W. Elder: When the pandemic started, we had a system that we had set up, and I’m the medical director for our direct-to-consumer telemedicine throughout our health system. We had a system set up whereby patients who had an MRN, who had established care with UC Davis, could open their phone, click on their phone, and see a provider. And this was the first step, but we realized this was really meeting the needs of many patients we were seeing or wanted to see.

And so we continued to work with our IT teams and our strategy teams and our operations teams to figure out how we could open the gate, really, to allow this access to everyone. And so, really, the past year has been a journey in that regard. We’ve opened that up now to patients who don’t yet have established care. We’ve opened that gateway now to patients who are proxy patients, so patients who aren’t established and are also, for example, under 18. There are unique compliance and legal issues to figure out how to do that and how to do that safely. And so we’ve gone piecemeal down this pathway, to the point where, as of two months ago, our product now, Express Care, provides access to everyone.

But the question, Kevin, that really is fundamental is: Even though that access is open, is everyone using it? And the answer is no. There are certain geographic and fundamental populations that we’re just not reaching out to and connecting with, even though we provided translation services, even though we provided kind of a pay pathway to get there and get the services they need. There still is a fundamental gap, and that is where this digital health equity gap emerges. And that’s what we want to do. We want to help fill that gap, to actually do something about it. And so Tammy Scott and I and many of our other colleagues have been really working hard to try to figure out how to close that gap and provide the care to populations when and how they need it.

Kevin Pho: And from your research and experience, what are some of the root causes that explain this digital health gap?

Joshua W. Elder: Part of it is that, let’s start fundamentally with broadband. I think we can look at the obvious continued gap. If you go back to the Rural Electrification Act, when FDR was emerging, in the early 1900s, you see that there were parts of our country, in Texas, for example, that still didn’t have electricity. We are at that divide yet today in terms of broadband, where there are wide swaths of communities that don’t have access to broadband services. Many are rural, and some are in our urban landscapes. So that provides a huge barrier to even entry into a market like this.

And there’s another gap. There’s a gap around having the right tools, having the right cell phone, having the right knowledge, having the right kind of literacy to figure out how to do this. So those are some obvious gaps, where we may have this access, and people may be able to use it if they desire to, but how do we connect those dots when there’s such a fundamental infrastructure gap? So that’s really the basis of the problem, in my mind.

But then there are a lot of gaps in terms of the literacy component that I think we can have a big impact on even today. And so Tammy Scott and I, part of our vision for movement in this space is to create really health navigators, but digital health navigators, in our community. That’s the work that we’re working on now, to help engage our community and figure out how to connect to these subgroups and populations, to be able to better meet the needs that they may have. And if they want to use this service, they’ll be able to.

Kevin Pho: So go into more detail about those digital health navigators. How exactly does that process work?

Joshua W. Elder: So health navigators have been around for some time, the promotora model of bringing someone from the community, from a population that you want to serve, and having really a relationship. It’s really centered in a triangular relationship between the patient, the provider, and then a navigator to help that patient navigate many of the challenges that health care faces. Now, on top of that, you have a digital landscape. Even patients who have potentially great health literacy in general may not have great digital health literacy. I see this many times in many populations. So how do we close that gap?

In our vision of this, what we’ve been working towards programmatically is to incorporate members from communities we want to serve and that want to be served, and then have them as an ally to not just navigate the health care challenges and the health navigation but also that digital literacy that is fundamental to using services like this.

Kevin Pho: So tell me some success stories about some of the initiatives that your program has done to help alleviate or solve some of the issues you bring up.

Joshua W. Elder: Well, about a year ago, Tammy and I started to see the value of looking into government funding or additional funding to potentially build the road map to this end, to closing some of these digital health equity issues that we were seeing emerge in our program. And so we went about submitting a $1.7 million community project fund, or earmark, that recently the sub-appropriations committee of the House approved. It still has some work to go to get final approval, but I think that gives you probably a sense or a lens of what we’re trying to do.

But also, where I see some of the solutions fitting in is that we may be building, unfortunately, not an integrated model if we don’t start to think about how to better fund these initiatives. Because at the end of the day, at its core, these services should provide full access to everyone, not based on payer, not based on location or any number of factors. And the only real way to get there is to look at this as a fundamental right, but also to build the funding model to be able to achieve those ends.

Kevin Pho: What will the landscape of digital health be over the next one to two years? I’m reading that one of the big obstacles is from the payer side, in that in the next few months, a lot of payers aren’t going to pay for digital visits on par with in-person visits, and those certainly are running out. What do you see as the future, and what do you see as some of the obstacles?

Joshua W. Elder: I always am instructed by our past. I think the Affordable Care Act was a great instrument to understand the world we want versus the way the world is. The Affordable Care Act was created to diminish and decrease emergency department visits, and yet visits went up because patients desired them, both patients with insurance and without. Even as the insurance landscape emerged to have greater coverage, visits went up.

I believe that patients and our population, our society, will demand this, and we’re seeing that already. We’re seeing this emerge in the landscape, having a huge uptick in visits during COVID, 40 times the rate that we ever saw, but we’re still seeing 20 percent of care provided in this digital health landscape. So with having that embedded need and vetted desire, everything is motivated by what patients ultimately need and desire.

And I will tell you, as a parent, as a provider, the ability to see a provider when you need it, in the place you need it, and not have to do the logistical, sometimes the great challenge is to achieve the care ends of following up to a visit. It doesn’t replace all care needs by any means, but it’s another tool in our tool kit, and I think patients are starting to use it and demand it. And I think as more populations get exposed to this, that will further enhance really a demand to create both a regulatory market but also just a marketplace for health care that provides this for patients independent of their payer and independent of where they live.

Kevin Pho: We’re talking to Joshua Elder. He’s an emergency physician, and he co-wrote the KevinMD article “Digital health equity is an emerging gap in health.” Joshua, with your background in health inequality, can you comment on some of the resources that we need to alleviate that gap? And in your words, why is leaving that gap so important?

Joshua W. Elder: To me, it’s really about doing the right thing for patients, when I see just that individual connection with the patient and I see them access this maybe for the first time: a mother that’s trying to get to work, someone at work who just can’t take the time off for whatever reason, and this meets their need in that moment. That highlights the evolving value of this.

And I’d also say, in contrast to some of the more corporate entities in telemedicine, what is unique among tertiary care telemedicine, and what we’ve created, really, it’s the largest program of its kind in California, is that when patients see us, it’s not just seeing a patient. If you were a patient of mine and I was talking to you, this also would evolve into: Do you need labs? Do you need a referral? Do you need to see someone else? Do you need another specialist? Do you need help? Do you need a health navigator to navigate some of these issues with you? Do you need to have maybe a care nurse call you to help figure out where to go for some of these labs, or follow up those results with you?

So that, I think, sets the tone of what is possible. And in COVID, just to give you a highlight of this, many programs in telemedicine will be able to see a COVID patient and say, “Yeah, you might have COVID. Go get tested.” In our program, we can test patients. We can also call ID and get approval for monoclonal antibody treatment and get them set up in outpatient treatment the next day, forgoing the need to go to the emergency department and eliminating that as a potential risk to the patient and other providers. It’s just showing an evolving landscape of how this becomes complementary, not moving people away from the traditional health care but augmenting how they use their health care in a way that fits their needs.

And I think because of that, we are going to fundamentally need to invest time and energy to think through how to do this the right way. Fundamental to this conversation, Kevin, is health equity and digital health equity. Fundamental to this premise is: Are we doing this right? We have this new program. There’s no program quite like this. And so we’re moving north, and we’re trying to figure out: How can we do this in the right way? How can we do this ethically? How can we meet the needs of our patients in our communities and do it in a way that’s sustainable and involves, obviously, the community needs?

But it’s going to require an evolution of thought, and thought leaders like yourself, I think, emerging these types of conversations to help people really begin to digest what this should look like, and use it a few times as a patient, as a provider, and then start to come up with ideas to help us move on that path. And so while health equity might be defined as access, obviously we know, Kevin, that there are so many outcomes of health that we haven’t even discussed in this conversation yet, that obviously set a pivot to where we are moving. And I think that is a global conversation in medicine and in our society that we will have, and it will emerge once more people begin to use services like it.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Joshua W. Elder: You know, in the great despair of COVID, I know you, Kevin, and myself were talking before this, and we continue to fight the fight, so to speak, of a pandemic that has impacted us all in so many ways, fundamental ways. And it has fundamentally shifted my thinking to not a light of despair but a light of hope, that through this great crisis, I saw a great connection emerge. And I think that this is a moment of celebration, really, to see that there are things that have come out of this great, great challenge that will provide great opportunity, and already have.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

Joshua W. Elder: Thanks, Kevin, for having me.

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