https://www.ajmc.com/conferences/qcca-fall-2019/evolving-healthcare-beyond-the-conventional-walls-of-the-delivery-system
Evolving Healthcare Beyond the Conventional Walls of the Delivery System

Laura Joszt

The word “disruption” is getting thrown around a lot in healthcare as rising costs are forcing providers, payers, policy makers, and more to find new ways to deliver care at lower costs. However, Susan Dentzer, visiting fellow at the Duke-Margolis Center for Health Policy, doesn’t like using that word.

People in healthcare who think they are going to get disrupted feel threatened by the idea, but patients might not also like the idea of their care being disrupted.

“…I don’t think it’s the number 1 phrase patients want to hear,” she said. “When I think about all the people I know who’ve had cancer and had close relatives have cancer, die of cancer, etc, if they had heard, ‘it’s going to be disrupted,’ that would not be their immediate thought of what was good.”

During her keynote speech at the Quality Cancer Care Alliance’s Leadership Summit, held September 5-6 in Grand Rapids, Michigan, Dentzer instead focused on the evolution of healthcare as it moves outside the conventional walls of care. “Evolution,” she believes, is a word that everyone can agree is more acceptable and less scary or frightening to patients.

In her previous role as the president and chief executive officer of the Network for Excellence in Health Innovation, Dentzer helped to work on a roadmap for reinventing the US healthcare system, called Health Care Without Walls. Some of the big questions the roadmap asks and seeks to address are: “What can we do to take the part [of healthcare delivery] that is about exchanging information and move that to a more virtual context than we have done traditionally in healthcare?” Dentzer asked.

There are a wide variety of patients who could benefit from virtual care. Some of the patient profiles Dentzer outlined included an elderly woman with a cognitive impairment and a heart condition who is living on her own and wants to continue living in her home but cannot drive anymore, or a pregnant woman with a high risk of premature delivery who is working at a low-wage job and cannot take a day off work to go see her obstetrician.

The main hypothetical character profile and situation that the group created was Dave, a man in his 40s who lives on Kodiak Island in Alaska. He’s a relatively healthy person, but he develops a hacking cough that persists for months and when he finally goes to get care, the doctor detects a lump and thinks Dave might have lung cancer, but the doctor isn’t sure.

In the current situation, Dave would research lung cancer, find out he probably has non–small cell lung cancer, and determine he has to get to a major cancer center in New York for state-of-the-art treatment. Now he has to figure out how to consult with the clinicians there. Does he need to book an appointment, fly across the country, and stay overnight in a hotel? After he obtains advice on a treatment plan, then what? Does he move to New York during treatment?

In an ideal scenario, Dave could get his tumor tissue sequenced locally and the digital images sent to the cancer center in New York, he could get a telehealth consultation, his targeted therapy can be e-prescribed and then dispensed from a specialty pharmacy in Seattle, and finally his therapy can be delivered by drone to a critical access hospital on Kodiak Island.

While all of that is technically possible, this scenario would never happen.

“The system is not in any way organized around the patient or what the patient desires,” Dentzer said. But there might be a future where this can happen.

She explained that there are pieces of the future that we can already see in bits and pieces that will eventually grow and expand, and she highlighted some of them. Dentzer quoted science fiction author William Gibson who once said, “The future is already here—it’s just not very evenly distributed.”

Teleoncology, which can increase access to care and decrease costs of care, is taking place in some places of the United States. A meta-analysis of 20 studies of telehealth use in patients with breast cancer has shown that patients generally like it and are satisfied with care. Arizona has already made a major commitment to telemedicine and telehealth with a program launched in 1996 that includes telemammography and telepathology.

Telegenetics has been implemented at the University of Pennsylvania’s Abramson Cancer Center, which provides counseling via telephone and 2-way video conferencing to combat the shortage of genetic counselors.

LAUNCH, which stands for Linking and Amplifying User-centered Networks through Connected Health, is a project Dentzer is working on that provides broadband-enabled connected health in rural Appalachia. There is a lot of lung cancer in the region,  and patients will travel to the Markey Cancer Center and go home, but they will not make the regular trips back to Louisville, Kentucky, for follow-ups. This project will enable patients to be monitored in their homes and communities, but it needs a new payment mechanism and it needs universal broadband or 5G technology capability in rural Appalachia.

Dentzer also highlighted the work of Project ECHO, which launched in 2003 by the University of New Mexico to educate primary care providers on how to care for patients with hepatitis C so they could receive treatment in their communities without traveling long distances. India has been using Project ECHO to train community health workers to conduct cancer screening in remote villages.

“If this can happen in India why aren’t we doing enough of this in the United States?” she asked.

Other countries are utilizing technology more than the United States, she added. While US physicians cannot use WhatsApp because it’s not totally compliant with the Health Insurance Portability and Accountability Act, Israel has 96% of its physicians on the app and 71% use it for communication of patient information and consultations.

“Think about how the rest of the world is working in low-resource settings to take advantage of these capabilities,” Dentzer said. “And it really does kind of put us to shame.”

The United States is moving into an era of what Dentzer said has the “potential for democratized cancer care,” in which patients have greater access to care, more knowledge, and more power.

Making the needed changes to have Dave’s vision of care come true would result in more convenient care and an expanded provider base. Some of the downsides to keep in mind, she noted, are that this increased use of technology might not be good for all patients; making it easier to access care using telehealth might mean people utilize it more, which increases cost; there remain privacy and security concerns; providers will have more data to sift through; and a number of business models will be severely disrupted.

“When it comes to disruption or evolution…around cancer care, the status quo is not an acceptable option for us,” Dentzer concluded. “We have got to move as a country and as a world to embracing more of these capabilities and making them a reality.”
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