Advancing Health and Wellness via the Smart Home

Part 2: Five Critical Elements

An effort to advance health and wellness via the smart home will require the following five critical elements: 1) adequate connectivity available to a critical mass of households, 2) compelling applications, 3) a clear business case for patients, healthcare providers and payers (including state and local governments), 4) a supportive regulatory environment and 5) demonstrable outcomes that telehealth services.

In this post, I explore the extent to which these critical elements are in place.

Adequate connectivity available to a critical mass of households

A successful deployment of healthcare applications via a smart home platform depends on the ability to reach a critical mass of users. A serviceable market of potential end-users must possess effective in-home networks and high speed access to the Internet that enable seamless data collection and dissemination. Drawing on recent data, a strong case can be made that — for the first time — a critical mass of smart households is now present in the United States.

The last few years have included a dramatic sea change in the number of households where ultra-high speed broadband service is available. Between 2016 and 2020, thousands of communities and millions of households have new-found access to broadband networks capable of gigabit per second speed service (“gigabit service”). This is largely a result of a large-scale investment in network upgrades undertaken by the cable providers across the country.

According to data collected by the cable industry’s trade association, NCTA, in December 2016, 4% of households served by cable companies had access to gigabit service. By December 2019, the percentage of households served by cable companies that had access to gigabit network had increased to 80%, with some cable operators reporting that 99% of households in their service area have access to gigabit service.

Of course, the fact that more than 80% of households have access to advanced broadband networks is not sufficient. For reasons made abundantly clear during the COVID-19 pandemic, all households need access to robust connections to the Internet. Efforts to ensure that all American households have access to ultra-high speed continue. Cable operators and other Internet Service Providers (ISPs) continue to invest in network upgrades. Advancements in fixed wireless broadband technologies and recent decisions by the FCC to make available spectrum well suited to rural deployments will enable new avenues to connect communities and households in underserved rural areas with robust broadband service.

As efforts to expand the availability of robust broadband service are on-going, an increasing number of consumers are taking advantage of ultra-high speed connectivity being offered by ISPs. In so doing, these consumers have created a potential market of tens of millions of households with access to a powerful platform through which remote services and innovative applications can be delivered.

Compelling Telehealth Applications and Services

Hundreds of companies have developed applications and services that enable healthcare providers and patients to interact remotely. According to the National Venture Capital Association (NVCA), between 2009 and 2019 venture capital funds have invested more than $2B in companies offering innovative products or services best described at “telehealth.” In an apparent response to potential growth in the market due to the COVID-19 pandemic, telehealth firms raised $788M during the first quarter of 2020, amounting to three times the funds raised by telehealth firms in Q1 2019.

The Consumer Technology Association (CTA) and American Telemedicine Association (ATA) have developed a directory to help healthcare professionals and patients identify digital health technologies that connect patients and clinicians with health care solutions. Launched in April 2020, the directory includes 170+ service providers, application developers and medical device makers. Companies listed in the directory offer applications and services that enable/support telemedicine, diabetes care, remote patient monitoring (RPM) and telemental health.

It is important to take note of the diverse array of market segments in which telehealth firms operate. So-called telemedicine firms, including Teladoc, operate in countries across the globe and connect patients and their healthcare providers offering patient engagement and real-time, two-way video virtual visits and increasing access to care. In 2019, Teladoc reported 37 million paid memberships and another 19 million fee-based visits. RPM firms, including Mcare, offer technological platforms that support monitoring and provide access to resources that enable elderly to live independently and help those with chronic disease to manage their condition. Other companies, including Trappollo, partner directly with hospitals, healthcare providers and insurers to provide coordinated care using serval technological tools including digital engagement tools, telehealth capabilities and monitoring functions. Taken as a whole, the telehealth sector offers a new vision of connected health wherein technology-enabled engagements augment in-person clinical visits.

Reflecting on Trapollo’s 10-year history, its CEO John Aldridge articulates how a vision of connect health will transform the lives of patients, providers and communities for the better.

“As the demographics in the U.S. change and more people are willing to use technology as part of their healthcare delivery, we see the adoption of technology enabled connected healthcare rapidly increasing. We see the home and office environments as the next venues for healthcare delivery. Our solutions and services will support preventative care, healthcare as part of one’s daily routine and aging in place.”

During the time of COVID-19, behavior change among patients in favor of using at-home technologies as part of their healthcare delivery (a change that John Alridge suggests will be a attributable to demographic changes) has occurred seemingly overnight. Teladoc reported an increase of 50% in visit volume during the first week of March 2020. Whereas, Trappollo reports that the number of patients with access to the Trappollo-enabled programs had grown by 3,000% during the first weeks following the emergence of COVID-19. New patient behavior is particular apparent in at Boston Children’s Hospital where the Chief Innovation Officer reports that the hospital is doing more virtual visits in a given day than it did the entire year in 2019.

Accompanying the dramatic increase in the number of patients and providers using telehealth services since the emergence of COVID-19 is polling suggesting an increase in patient satisfaction. A quarterly survey of patients and providers called the PX Pulse shows that while visits to primary care providers is down, patients surveyed report a 13% increase in satisfaction with overall healthcare quality compared with the January 2020 survey. Additional polling related to patient and provider satisfaction with telehealth will become available in the coming months. The Alliance for Connected Care is posting the polling as it becomes available in a repository on the organization’s website.

Business case for In-Home Virtual Care

Even before the emergence of the COVID-19 pandemic, hospital systems and healthcare payers, including Health Maintenance Organizations (HMOs), large employers, insurance companies, were enthusiastic adopters of the applications and services offered by telehealth companies. For example, in 2017, 52% of Kaiser Permanent’s 100 million annual encounters in 2017 were virtual visits. In that same year, the Cleveland Clinic hosted 25,000 virtual doctor visits, up 160% compared to the year before. A 2019 study by the Healthcare consulting firm Mercer found that 88% of employers offer connected health services through their employee health plans. A study released by the American Medical Association (AMA) found that telehealth use grew by 53% from 2016–2017.

For hospital systems and payers, virtual healthcare applications can help them provide effective and cost-effective healthcare while at the same providing compelling solutions to vexing problems (e.g., physicians and nurse shortages in rural areas). A particularly acute challenge that is how best to care for 117 million Americans managing one or more chronic diseases. Experts believe virtual care solutions can help address this challenge. According to the Centers for Disease Control and Prevention, 90% of the nation’s $3.3 trillion annual healthcare expenditure is spent on individuals with chronic and mental health conditions. Hospitals and HMOs that seek reimbursement from the Center for Medicare and Medicaid Services (CMS) have incentives to minimize patient readmittances and, therefore, have interest in utilizing solutions that help monitor, support and encourage patients when they return to their homes after receiving treatment in a healthcare facility.

Despite enthusiasm from payers and hospital systems, patients and physicians (at least before the emergence of the COVID-19 pandemic) had lagged in their embrace of telehealth applications and services. In 2018, only 9% of employees say they used available telehealth services, a 1% increase from 2017. Expert observers of the space believe that the lack of rapid, widespread adoption of telehealth by patients is most likely a function of regulatory constraints and consumer habits. While apparent reluctance by physicians to adopt virtual care applications is likely a function of the rules and payment structures governing telehealth and the challenge of incorporating new technologies into a medical practice.

Regulatory Environment

Before recent regulatory waivers that have accompanied the emergence of the COVID-19 pandemic, organizations including the American Hospital Association had raised concerns that federal and state regulations have constrained the utilization of telehealth. Medicare, for instance, would only pay for telehealth services only in qualified rural areas. Additionally, CMS required that the telehealth be conducted in qualifying facilities — a requirement that had ruled out telehealth engagements with Medicare patients in their homes.

The following legal and regulatory issues have had a significant impact on the adoption and utilization of telehealth services and, by extension, on prospect of advancing health and wellness via the smart home.

· Coverage and payment issues. CMS, State Medicaid programs and private insurers have their own rules that govern whether and the extent to which they will reimburse and reimburse healthcare providers for telehealth services.

· Health professional licensure. Every state and territory has laws that govern the practice of medicine. Existing licensure laws present barriers to providing telehealth services across state lines.

· Online Prescribing. If the telehealth services are to be effective, convenient and efficient, providers must be permitted to prescribe medications to their telehealth patients. Concerned about fraud and abuse of controlled substances, states have of variety of laws governing online prescribing. The patchwork of laws creates challenges for Telehealth providers operating in different states.

· Privacy and Security. Because interactions with telehealth patients involve communications technologies, these interactions have increased risks of violating HIPAA’s privacy and security regulations. Providers must examine carefully privacy policies and practices and may need to adopt technological tools designed to authenticate patients and providers and secure protected health information.

In response to the fact that many medical offices are closed during the shelter-in-place response to COVID-19, CMS, State Medicaid program and private insurers have relaxed restrictions and issued waivers that make telehealth services — including services delivered to patients in their homes — more accessible. It is uncertain whether some, none or all the regulatory changes will become permanent. At this point, CMS has only committed to relaxing restrictions on telemedicine reimbursement “for the duration of the COVID-19 Public Health Emergency.”

Research Pilots Demonstrating Positive Outcomes

Compelling research projects and studies support a conclusion that telehealth technologies deployed in home can lower costs and improve health outcomes across a wide array of conditions and treatment protocols.

• A University of Alabama-Birmingham pilot program has demonstrated the effectiveness of replacing office visits for dialysis patients with comprehensive telehealth exams.

• A Mississippi pilot program to provide remote monitoring for diabetes patients saved nearly $350,000 in healthcare costs in just the first six months

• A study conducted by the Veteran Health Administration found that a program using telehealth for home heart monitoring resulted in a 51% reduction in hospital readmissions for heart failure.

• A study of the University of Virginia’s Care Coordination Remote Patient Monitoring concluded that hospital readmissions have been reduced by more than 40%.

• A 2017 national study of virtual care program designed to address chronic pain found that participants experienced significant reductions in depression, anxiety and stress symptom severity.

• A 2017 study of Los Angeles Counties deployment of the eConsult telehealth application concluded that theapplication was a promising and sustainable intervention that improves access to specialist care for underserved patients.

• A 2014 study of North Carolina’s Statewide Telepsychiatry Program concluded that the use of telehealth resulted in patients spending significant less time in local hospital emergency departments and lowered the likelihood that patients returned to the hospital emergency department for treatment.

More data is needed to better quantify the positive impacts of telehealth applications and services. Federal agencies, universities, hospital systems and state and local government should look for ways to advance peer reviewed studies of virtual care solutions to advance healthcare outcomes in their communities should consider sponsoring research pilots. Application developers, technology companies, ISPs should develop showcase deployments that illustrate that compelling applications can be securely and reliably delivered to patients in their homes.

Next up?

In the next blog post, I will make a case that state and local governments should be enthusiastic adopters of telehealth and Remote Patient Monitoring technologies and should develop and support Smart Community initiatives designed to advance health and wellness by leveraging the smart home.

About this Medium Site

On this Medium site, I explore an array of topics related to the transformative power of smart and connected communities. A central question for this observer of the so-called smart city movement: how will municipalities develop, deploy and support smart and connected community projects at scale?

I welcome feedback and comments from readers.