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Healthcare Upside/Down: Digital Health and the Tele-Presenter: Addressing Inequity in Healthcare

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ECG’s radio show and podcast, Healthcare Upside Down, offers unfiltered perspectives on what’s working in US healthcare and what’s not. Hosted by ECG principal Dr. Nick van Terheyden, each episode features guest panelists who explore the upsides and downsides of healthcare in the US—and how to make the system work for everyone.

The emergence of telemedicine as a means to ameliorate patient access issues was one of the few bright spots of the pandemic. Telehealth platforms preceded COVID-19 by many years, but their adoption soared as healthcare organizations scrambled to find ways to treat patients who, by choice or by mandate, could not be seen in person.

The digital health genie is now out of the bottle, with providers having invested in telemedicine tools and patients enjoying the utility and convenience of receiving a clinical diagnosis from the comfort of their home or office.

But even as the pandemic ushered digital health into the mainstream, it also amplified the inequities in our healthcare system. Despite the newfound popularity of digital tools, they fail to bring relief or additional benefit to underserved populations.

At the core of the problem is lack of access to technology and broadband. According to the FCC, nearly 17 million school children don’t have internet access at home, and some 19 million households in America are in rural areas that remain unconnected. By one account, more than 157 million people in the US aren’t using the internet at broadband speeds.

Those figures loom large over any attempts to solve health access issues with digital technology, and there are no quick fixes for such massive infrastructure problems. But health systems may still have an opportunity to reach underserved patients through digital tools.

“It’s very important for health systems to understand that we have to approach this as a partnership issue,” says John Jenkins, MD, an internal medicine physician who runs special projects for Greensborough Area Health Education Centers (AHEC) in digital health and is also a clinical academic resource director at the Greensborough Campus of UNC Chapel Hill, Cone Health. “We have the potential to work with trusted partners that are in locations that already have internet access, such as our schools, our community centers, our churches.”

Dr. Jenkins is solving the lack of access in a unique and innovative way—by implementing a digital health program in a North Carolina elementary school. On episode 15 of Healthcare Upside Down, he describes the program and how it can be a model for expanding patient access in underserved communities. Here are three takeaways from our conversation.

Understanding the relationship between access and equity.

Dr. Jenkins’ involvement in digital health dates back to 2013, when he led Cone Health’s efforts to launch a telehealth program for the health system’s patients. But that was long before anyone had ever heard of COVID-19, and telemedicine was something of a novelty. “One of the things that I realized was that I was creating access for people who already had access,” Dr. Jenkins says. “I was really solving for convenience. And much of the pre-COVID literature talked about convenience as a motivator for digital health.”

Convenience quickly turned to necessity with the onset of the pandemic. And for Dr. Jenkins, the crisis also exposed inequities in the US healthcare system. Despite telehealth’s potential to expand providers’ reach, lack of access to technology meant that digital tools would remain out of the hands of many individuals and families. “What I learned during COVID, as I worked with safety net practices across North Carolina to help them start their digital health programs, was that access doesn’t always equate to equity,” he says. “And equitable access was something that we needed to work toward as a goal in our healthcare systems.”

The need for partnership.

With millions of people unable to use high-speed broadband—a problem that will take years to solve, even with adequate funding—Dr. Jenkins realized that partnerships between health systems and community organizations and institutions that already had internet access was the quickest path to a near-term resolution. He initiated a pilot project at an elementary school in Greensboro that would connect students with pediatricians via a digital health platform. “Children are very comfortable at school, and they’re there eight hours a day,” he notes. “We decided to start at the earliest age in elementary school, because problems that start in elementary school persist through junior high and into high school.”

As any true partnership should, the program is intended to address issues faced by each stakeholder. “We had to sit down with our partners, understand the problems they were trying to solve, and how we could provide health access for the students in school,” he explains. “The first partner is the school. The problem they need to solve is keeping kids in school, because educational performance is directly inverse to absenteeism.

“Number two is the health system, which looks at increased cost from many children of poverty and color using our emergency rooms for routine care,” Jenkins continues. “And we see this by data that shows a peak in access between the hours of 5 and 9 p.m., because that’s when their parents get off work and can take them to the emergency room for care. So they don’t have equitable access to a pediatrician during normal hours. Then there are social determinants that we must look at—transportation, the fact that the parents can’t get off work to take the child to a doctor’s office, and the fact that they have lack of health literacy and lack of digital literacy, and sometimes lack of trust.”

How it works.

In order to make the program valuable for children, parents, and the school, Dr. Jenkins realized that the virtual visits had to resemble in-person visits as closely as possible. Setting up a camera and TV screen in the school wouldn’t be enough. The visits would be augmented with digitally enhanced tools, including otoscopes and stethoscopes, to facilitate a high-quality examination. But a critical piece was missing.

“What do we as providers experience every day in our offices?” he asks. “A staff that supports us.” That led to the idea of what Dr. Jenkins calls a tele-presenter—an individual who coordinates the visit. “The tele-presenter creates the case, brings the child in, takes the vitals, connects the parent to the virtual exam room, and then manipulates the devices in the virtual exam room to give the pediatrician an optimal exam experience with the child.”

There are still barriers to the program’s expansion, notably the expenses associated with paying for a full-time tele-presenter. But Dr. Jenkins points to three early outcomes that demonstrate the program’s promise. “Number one, the vast majority of the children we saw were able to return to the classroom. So we prevented absenteeism. Number two, the parents told us that if they didn’t have this option, they would have had to go to the emergency room with the child. So we were able to prevent the emergency room utilization. And number three, which is really critical, we were able to start to understand our partners’ additional needs, and we’re moving into what I refer to as a ‘whole-child approach’ to digital health,” he says, which will extend to behavioral health, therapy, and health promotion at school.

Can a telehealth partnership make a difference in your community?

Dr. Jenkins talks further about innovative solutions to
health inequities.

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