Inverting the Model – How COVID-19 Turned Telehealth Literally Inside-Out

Telehealth is not new to healthcare. Indeed, it can trace its roots to well before World War II with the availability of field telephones to provide a ‘virtual’ presence of a field medic to support battlefield soldier wound operations and procedures. If we jump to the early 1960s, we see its application extending beyond the reaches of our planet for use in monitoring the health status of NASA astronauts circling the globe under the exotic sounding name of ‘Flight Surgeon Operations”.

Fast forward to today, and we encounter a whole new set of telehealth services bundled under the lexicon of Consumer Digital Health. These terms include “e-visit”, “v-visits”, each representing a form of asynchronous (electronic messaging) or synchronous (video and voice APP) encounter between the patient and a care provider. Even more recently are virtual scheduled visits, the latter of which may be flat fee based or require advance insurance payments, depending on the particular business model implemented by the healthcare organization or the servicer for the healthcare organization (often white-labeled). Significantly, consumer enterprises and payers recognize the business opportunity of telehealth, and they are aggressively promoting their own telehealth versions aimed not only at consumer health but also at their wellness. Reinforcing this paradigm are data analytics, cloud storage, and mobility service operators who are essential ecosystem enablers.

While the afore-mentioned is predominately aimed at the consumer as a patient, healthcare organizations operate a separate and specialized form of telehealth services called tele-ICUs. Tele-ICUs are highly-sophisticated platforms used in an in-patient setting to provide real-time, continuous monitoring of patient vitals. These solutions developed mostly independently of the Consumer Digital Health solutions described above, and a distinguishing feature is their use of proprietary and/or secured wireless networks. Examples of tele-ICU vitals monitoring include but are not limited to heart rate, blood oxygen levels, pulse rate, temperature, and blood pressure. This data is quite voluminous, requiring costly data centers. Furthermore, tele-ICUs generally employ highly-specialized clinicians to monitor patient vitals. Accordingly, the tele-ICU is not designed to scale to the patient load levels of a pandemic such as COVID-19, nor is it suitable for at-home patient monitoring, which is highly desirable for obvious reasons. Simply put, the economics and limitations of the technology make it impractical and unsustainable for this use case. Similarly, Consumer telehealth solutions are not optimal in such a situation where there is need for repeatable, consistent, and reliable patient provided data. The reasons for this are that factors beyond the patient’s control may prevent and/or impede access to critical vitals from patients. Some key examples include unavailability of a high-performing data networks, the patient’s level of disease acuity, or poor consistency and/or variation in patient compliance at specified or required monitoring intervals (intentional or unintentional).
The COVID-19 pandemic has forced the healthcare industry to explore new avenues to address patient care, especially as it relates to pre and post diagnostic care pathways. Many stories abound about patients who are struggling to regain their health only to suddenly and precipitously fall very sick in a short and rapid timeframe. When we combine the need for patient vitals monitoring at-scale with other key issues facing the frontline healthcare workforce, the combination creates a powerful incentive to develop and operationalize solutions to address such shortcomings. These latter issues include severe shortages of Personal Protective Equipment (PPE) such as gowns, masks, and gloves, heightened disinfection requirements due to contact spread, and the need for social distancing to combat aerosolized spread of the pathogen. Fortuitously, the healthcare industry has been able to tap the wireless industry to provide highly-available solutions to support the nation’s needs to deliver healthcare operations in the war against COVID-19.

While healthcare systems across the country began their journey with different starting assumptions, the net result that has been achieved is mostly the same: the deployment of Remote Patient Monitoring (RPM) with video and voice capabilities for low-acuity COVID-positive or non-COVID-positive patients in a clinically-monitored environment, that is scalable to address the needs of a pandemic. Additionally, such solutions are extensible to support patients who are may eventually be monitored at home, echoing the guidance from Italian physicians in terms of “lessons learned” about not spreading the contagion to busy and over-worked healthcare professionals as well as others in an Emergency Department (ED) setting.

What inverts the traditional telehealth model is its use in an in-patient setting, whether it be a traditional hospital facility, an ED surge tent, a clinic, a converted Physician Office Building (POB), or a converted convention center. Drivers of this new model include efforts to maximize the use (and in some cases, re-use) of PPE, the need to minimize physical presence with a COVID-patient, operational efficiencies to care for large numbers of infected patients, and fundamental limitations of other facility services such as a lack of established care infrastructure. Specific considerations of the latter for POBs may be the absence of nurse call buttons, the risk of insufficient wireless networking capacities, or a lack of vitals monitoring equipment.

Clinically, the model for low-acuity telehealth services in such settings will include vitals monitoring. In the case of COVID-positive patients, there are two key vitals of interest: a patient’s temperature, which physicians have found to be highly-indicative of the level of COVID acuity, and their pulseOX, a drop of which over time is a telltale sign of the disease’s progression. To manage large volumes of patients, non-continuous monitoring is essential, the frequency of which may be adjusted.

Technical characteristics include the ability to rapidly install and configure the service, meaning days and not weeks. Patients are provided with tablets and/or large form factor devices that are used for patient-to-care team communications. These end point devices are secured and feature an APP that hosts the video and voice chat capabilities. Significantly, these same end point devices also serve as aggregation nodes or gateways to support the transmission of vitals data from wirelessly-enabled IoT sensors such as the temperature and pulseOX monitors, typically via the Bluetooth wireless standard. The end point devices must be configured so that it doesn’t go dormant or to sleep, should a clinician want to conduct a telehealth monitoring session with the patient. As such, the end point device APP must have “auto-answer” capabilities. Similarly, the APP solution must be able to perform automatic data pulls of patient vitals, if initiated by the clinician, or data pushes if initiated by the patient. Finally, the APP platform needs to provide centralized or federated management of monitoring data either to a specified nurses station, a cloud-based platform for data continuity, or optionally a call-center and/or a designated off-site facility. Finally, the service must be standards-based, interoperable with and to other healthcare IT systems such as the Electronic Health Record (EHR) for reimbursement, and be both FDA and HIPAA compliant.

One of the key dependencies of this new telehealth service model is having flexible capability to support data transport and video communications sessions over a variety of private and public networks – and that includes near field technologies such as Bluetooth, mid-range technologies such as WiFi, and long-range technologies such as cellular modalities. It is also vitally important to be able to support multiple wireless operators given different available levels of service arising from geo-physical and building materials that dictate different propagation characteristics of wireless signals at different frequencies. Of special note for future planning when the pandemic subsidizes is the application of private cellular such as private Long Term Evolution (LTE) and CBRS to create highly-secure and robust networks to support healthcare operations.

The COVID-19 pandemic is forcing healthcare systems to adopt new approaches to providing care by leveraging a variety of technologies especially those of telehealth. What is impressive to watch unfold is how the wireless and healthcare industries have come together in such a pivotal role to deliver valuable care operations during these untoward times