How do you educate medical and nursing students when class is no longer in session? What about clinical training when hospitals are restricted due to COVID? It’s no surprise that remote learning and pre-recorded classes plus active lecturer-student discussions on Zoom (or more secure video meeting platforms) in the spring filled the gap of the first two years of med school, which are primarily tied to class instruction. For incoming and resuming classes, most have a mix of online and in-person classes, depending on school location. Nursing schools faced and resolved similar situations.
But what happens in the second two years, when lectures mix with in-person clinical learning? Most schools pulled students from clinical work in the spring, but some, like Mount Sinai in New York, continued. The University of Houston has developed some other approaches. Their medical school, starting this year, was co-founded with insurance payer Humana as part of the Humana Integrated Health Systems Science Institute. Nursing school students who would typically join nurses on house calls shadowed these nurses on virtual visits as part of their clinical training.
The Association of American Medical Colleges (AAMC) is also looking at ways to integrate telehealth into medical school curricula, and is publishing a guide this fall detailing core competencies around telemedicine. FierceHealthcare
Virtual reality (VR) is providing a more interactive training environment for clinicians with realistic scenarios and feedback. Computer simulations have been common for years in specialty surgery and diagnostics. With reductions in pricing on headsets like the Oculus Rift and Quest, several companies are introducing a different kind of virtual visit, one in a realistic clinic setting, simulating a pressured situation. These come complete with interaction between doctors, nurses, and other clinicians, can be ‘multi-player’, and provide performance analysis/feedback. This Editor noted Oxford Medical Simulation’s work with NHS England in Wessex on treatment for diabetic emergencies [News Roundup, TTA 3 Apr 19] and another pilot at OxSTaR (Oxford Simulation, Teaching and Research) center [News Roundup, TTA 8 Aug 19]. In surgery, Southern Methodist University (which has a leading graduate school for video game design), Virti, and Medical Realities (the latter two UK firms) have pioneered training in US, UK, and Europe plus specialized trainings for surgeons in Africa replicating conditions faced in ORs there. The trainings not only teach procedure, but reduce surgeon and fellow clinician stress. Digital Trends
This Editor recounted last night in the article below on The TeleDentists’ fresh agreements with Cigna and Anthem the observation of a former associate who has been in the thick of the remote patient monitoring wars for some years that telehealth/telemedicine has progressed 10 years in 2 months. Seema Verma, the head of the Centers for Medicare and Medicaid Services (CMS), stated to the Wall Street Journal (paywalled), “I think the genie’s out of the bottle on this one. I think it’s fair to say that the advent of telehealth has been just completely accelerated, that it’s taken this crisis to push us to a new frontier, but there’s absolutely no going back.” Even in a short period of time, CMS-reported telehealth visits as of 28 March trebled from 100,000 to 300,000. When the April numbers are in, it would not be surprising to see it grow well into seven figures.
The genie may be out of the bottle, but what will the genie do? Genies are, after all, unpredictable, and fly around. Out of the smoke, some educated guesses:
- Insecure, non-HIPAA compliant audio/video platforms will be the first which should be struck from CMS approval. Zoom has become a hackfest, with all sorts of alerts from mobile providers like Verizon on how to secure your phone. (An organization of which this Editor is a member had a panel this week completely disrupted by a hacker in five minutes.) Skype’s problems are well known. The winners here will be telehealth platforms that integrate well with EHRs, population health platforms (or may be part of population health platforms), and have robust security.
- Primary care practices and specialists, who’ve been surviving on non-F2F visits, will be adjusting their practices to patient demand, and integrating telehealth with physical visits in a way that their patients will prefer. This means a search for integration of EMRs/EHRs with secure platforms and reconfiguring areas such as care coordination. If planned correctly, this could create better management of patients with multiple chronic conditions.
- Actual physical visits will rebound, creating financial pressure on Medicare, hospitals, and private payers. How many people’s health has declined in two-three months is key. Small practices, who may see this first, will see another level of pressure, because they will be held to their Medicare quality metrics in value-based models even if adjusted. Hospitals will also rebound–if they are able. The dark side: private payers may run the numbers and scale back on benefits for the 2021 year especially if COVID is projected to make a return.
- Behavioral health may benefit, yet drive individual practices and a wave of retirements, or a consolidation into clinic or group settings. There’s a reason why Optum is buying out AbleTo; we may see a wave of competitor acquisitions in this area with the emphasis will be on cognitive health and short courses. Why retirements? Many psychiatric practices are still independent, concentrated geographically, and the average psychiatrist is over 50. Psychiatric EHRs are both costly and not particularly suited to practices. If faced with technological challenges, a lot of MDs and senior clinical psychologists may very well exit–threatening clinics which need MDs to legally operate.
- Rural health’s failure accelerated. USA Today’s analysis pinpointed at least 100 rural hospitals to close within the year. They already operated on thin margins, but with COVID expenses for additional equipment, the closing down of more profitable elective procedures and dependence on Medicaid, the over 1,100 unprofitable hospitals, over half of which are the only hospital in their county, have received a body blow. HHS allocated $10 billion to rural hospitals and clinics of the $100 billion aid package, but it may be too little and too late. Becker’s Hospital Review continues to track the bankruptcies and closures. Here there are no easy solutions from the digital health area.
- A culture of cleanliness should accelerate. If the genie pulls this out of the bottle, one major benefit will be that hospital-acquired infections will decline. Effective sanitization methods that reduce human application and scrubbing will be the ones to look at: disinfecting foggers and UV full room or area systems–or combinations of same. Cleanliness and lack of virii and bacteria may become a new metric. Look and bet on companies that can provide this, from rooms to computers/mobile tablets and phones.
Readers can help with these prognostications and especially how they will play out not only in the US, but also in the UK, Europe, and worldwide.