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Dr. Maddux: Technology is transforming the health care industry landscape. Patients are expecting experiences that align with their digital first daily lives. Clinicians need to provide better onsite care, remote patient monitoring and telehealth services while ensuring data privacy and enabling time saving automation for more personalized patient care improvements. Dr. Shelly Nash, Senior Vice President and Chief medical information officer for the Global Medical Office, at Fresenius Medical Care, is joining us today to discuss connected health. Welcome, Shelly.
Dr. Nash: Hi, Frank. Thanks so much for having me.
Dr. Maddux: Let's start with, you know what is connected health.
Dr. Nash: When we're talking about connected health, it's a term to really talk about the application of some of the things you already mentioned, to talk about the use of digital tools on technology overall to health care. So it could be talking about telehealth, it could be talking about electronic health records, we could be talking about health information exchange or the ability to use technology to transfer information between health care providers.
And it's really even more than that. It includes things like wearables, patients have devices in their homes, they have health trackers, and they can download apps all the time. So it's really an inclusive term to talk about that whole ecosystem of technologies that are available and being used nowadays.
Dr. Maddux: So let's talk about the lens of the physician and the nurse on the clinical care team. What's the benefit of connected health for that group?
Dr. Nash: I think there's a lot of benefits actually. and this is something new in the sense of, 30 or 40 years ago, we didn't have patients having applications where they could download information. But when we start thinking about what this can do for clinicians, if you are a physician and you have to see 40 patients in your office a day, you only get 15 or 20 minutes with that patient.
So connected health really allows you to get more information about what's going on with patients, for example. So if they're monitoring their blood pressure or using a glucometer, they can download all that information perhaps to an application that then you can see. And if the technology set up correctly, you can even have that imported into your electronic record systems.
For clinicians, it gives you a lot more information about what's going on with the patient.
Dr. Maddux: So that's effectively the diagnostic side of things. What about the therapeutic side do connected health applications offer us opportunities to actually provide care?
Dr. Nash: I think they absolutely do. One thing I didn't mention when I was talking about connected health is it also includes just data. Data is being generated every single day and then we can take this data and look at it for trends and apply machine learning and artificial intelligence and use it to predict things like; are patients more likely to have a bad outcome.
Are they developing an infection? If we're looking at things like their pulse and their temperature and all of that. There's a lot of opportunity to look at all this data and to glean, shall we say, insights that can then be used for treatment.
Dr. Maddux: What's the benefit of connected health to an individual patient that's receiving care?
Dr. Nash: I think there's a lot of benefits on that side, too. If you think about it, number one, patients only see doctors for a small period of time, right. And connected all depending on what aspect we're talking about. We can think about it as being convenient in the sense of if they can do a telehealth visit, you know, it may allow them to not have to travel.
Wait in the office during COVID, we saw that. But it also allows them access perhaps to doctors who are not within the region, something like that. They don't have specialists in their area. They can do telehealth visits on that. But it's more than that. It actually allows them the ability to see information about their visit.
When they say that patients only understand a quarter of what a doctor says, they can go back in and look through a portal at what the doctor said. There's a whole initiative around sharing notes. Open Notes is what it's called in the U.S., where we're actually sending the complete note, not just a summary, but it allows patients, the ability to do things like read what all their meds are, see what the doctor said, what's the plan?
If they didn't understand, they can share this with other people, right? They could share it with family members who might have more of a medical background. And they can also track things themselves. It shows that they can be more engaged and really understand more about what's going on in their own care.
Dr. Maddux: In kidney disease care, we're trying to move more patients into a home environment where they're engaged more directly in the provision of their care. To what degree is connected health a required element so they can feel comforted by the fact that somebody is keeping track of what's going on with them when they're at home?
Dr. Nash: I think the question is, is it required or is it a luxury? I think it's a luxury. But you could also make the case that it's required because you've got patients doing dialysis at home and the machine data can then get sent over to a clinical care team that can keep track of it and see what's going on.
I would imagine it would make patients feel much more comfortable to know somebody watching that they can proactively reach out to the patient if need be. also there's the ability for the patient to just on a convenient side if we have the setup correctly or if the patient's using the right device to have the information flow in automatically, they don't have to necessarily manually put in all that information themselves.
It's the same thing for other areas as well, like heart failure. There's a lot of management of heart failure patients with remote devices as well. It's making people a lot more comfortable with wanting to do things at home and feeling comfortable. So they're not alone.
Dr. Maddux: Our products group and our medtech division in care enablement obviously utilize for peritoneal dialysis, Canexis and those tools. And next-to-me for the NxStage System One machine. How important is the diagnostic information that we’re receiving from those devices, and do you consider it a critical element at this point?
Dr. Nash: I think it's very important. Number one, they can receive information just about the machines, right, to see if something looks wrong with the machine and proactively reach out to the patient. We can also, as I said, for the clinician, they can look at trends and they can look at what's going on with the patient to try and adjust the dialysis prescription.
It's paramount to have that information and have connected health. I don't know how you would do it without connected health, but I guess you could do it without connected health. We've made leaps and bounds in the ability to monitor things and to really proactively reach out to patients because of these technologies.
Dr. Maddux: You and I have talked in the past a little bit about the impact that generative AI may have in the way we provide care. How does generative AI, in your view, ten years from now connect with connected health?
Dr. Nash: There's a lot of ideas. Whether it's the generative AI is going to be used by the patient and the patient will be able to not just ask questions, but ask questions and then gain insights from using a chat bot. We're seeing a lot with chat bots being created where patients can ask questions and then decide perhaps what they need to talk to the doctor or if they don't be directed in the right way.
On the clinician side, it may be the same thing. Whereas this generative AI can be evaluating some of the data for the clinician because there's so much data coming in. we can't humanly look at all of it immediately. But if we have some help from some type of artificial intelligence or generative AI that can then analyze it and kind of direct us as the nurse or as the physician as to what's important.
So I think it will play a big role. It'll be interesting to see how big of a role it will play.
Dr. Maddux: Let's turn to another perspective, and that is research on connected health and the impact of what is the work that needs to be done that shows connected health isn't just a luxury, but in fact a necessary component of good clinical care.
Dr. Nash: What we're seeing is like everything in medicine, right? We tend to adopt things slowly as physicians and as a medical community because we don't want to adopt something just to adopt it because it's the shiny object, as you're saying that we want to find out if it's really going to do us some benefit.
So there have been some studies for example, around telehealth, COVID really obviously accelerated that. But, CMS was very, as you know, stringent in the United States around reimbursing. They were very worried that the use of telehealth would, number one, increase utilization. People would just start trying to do telehealth visits overall and also they were concerned that patients wouldn't be able to use it, that Medicare patients would have difficulties with the technology and that it would show poor outcomes for patients.
So I think COVID was an interesting research experiment in this area, because they went from something like 800,000 patients using telehealth to 52.7 million visits. So, we have a big group of patients that used it. And what they saw is looking at the data retrospectively, they saw that, number one, patients actually were able to use it.
They didn't have a lot of complaints about the technology they caught on. Number two, they didn't see any significant differences. And this is just generalities around especially with chronic disease management around patients that do telehealth versus coming in in person. That's initial research. But CMS, for example, is extending most of the waivers in the U.S. to do more research, because what we need to do is to find out long term, is there a difference when patients are not seen in person or if they're seen via telehealth?
It'll be the same with all of these other areas. in the US hospital, at home, that's a big thing. Now they want to have a lot of patients being cared for, even for acute conditions like pneumonia at home. So we need research to see do patients who have care at home do as well. Are there unknown outcomes.
It'll be really important to see where the where the data falls. The initial data, like I said, for most things, is not shown harm. the patients who are seen, at home or for a lot of chronic conditions. But we still have to see where it goes to make decisions about what that standards of care will be.
Dr. Maddux: You've had a number of interests in health equity and have participated actively in a number of our health equity efforts. Does connected health reduce the divide between marginalized populations of patients and others, or does it increase the divide?
Dr. Nash: Some studies will say it reduces the divide because, for example, there are what you can think of as health care deserts, right? So there may be places where patients don't have access and it could be marginalized groups. It could be it's hard to say which groups, but people that are either in an underserved area so connected health allows them, as I said, to see specialists that they might have to go hundreds of miles to see.
Then there's the concern that in some areas patients don't have Internet, so they don't have the digital tools to do it. But I think in the U.S., we're starting to see changes in that because there's a lot of programs from the government to give people cell phones. And we're making most of these digital tools and tele-visits and even trackers via mobile applications.
So it will decrease. And what they saw as it wasn't just rural patients using telehealth. A lot of urban patients were using telehealth as well. So I think it decreases it. that's a discussion point between some of the experts. But that's my opinion.
Dr. Maddux: How much, in your opinion, do you think we should be advocating for things like the Rural Broadband initiative and things that are really outside of the pure health care sector but are actually in the telecom sector?
Dr. Nash: We should be advocating for that because now health care is not just health care. Like we said, it's different. It's not just, oh, we need a bus to get the patient to come in. I think that we have to think of communication tools like that. like Internet is very important for patients.
If we want them to do home therapies and download their information or have it downloaded into the cloud, I think as an organization, it's the right thing to do and that we should be advocating for that.
Dr. Maddux: Today, most of our surveys of patients and other such things, not the ones we do internally here at Fresenius Medical Care, but the ones that we do from a regulatory standpoint, the ICAP survey and other things, they're all on paper still. What's it going to take to actually move this into a digital connected environment?
Dr. Nash: Well, first of all, it takes us as medical leaders to advocate for that. That's change management, right? Some people are like, well, it's always been that way. It's okay to do it that way. And we tend to underestimate our patients, and we've seen that with just some of the work we've done here with training tools using an iPad. Some people with the organization may say, Oh, patients don't need to do this.
They won't understand how to do it. But I don't believe that's true at all. And we had some really interesting feedback from clinical services around patients that were 90 years old and able to do things online. once we get the decision as an organization that we want to be able to do things online, the federal agencies,
If it's something that needs to be reported, they're all moving as well. They're funding a lot more digital initiatives out of CMS. We will have the option. Some of these agencies have been very good in not requiring us to do things digitally, report certain measures and quality programs, but a lot of that's changing. So, I think it'll just take attention to it.
The technology isn't going to be the hard part. It's going to be the change management and the workflow changes.
Dr. Maddux: I've advocated that nephrology needs to move further towards the ability to offer research opportunities to any patients wherever they are, much like oncology has done for many cancers. Do you think the connected health environment offers an opportunity for people to participate in clinical research through distance-based consent and electronic consent and other such things in ways that we haven't used it before?
Or do you think there are still the barriers of you've got to be at a research site, you've got to be with somebody that is conducting the research?
Dr. Nash: No, I think it does offer a lot more opportunities because people could do a tele-visit with someone. I think I even read online that UAB. that during COVID was doing a lot of their transplant referral appointments via telehealth, the initial one.
So it could be the same thing for research. People, maybe, as you said previously, would have to drive to talk to the research coordinator. Now with Connected Health, they won't necessarily have to do that as long as they're made aware of the opportunity. And the other thing is, with all the data we're getting, we could more easily identify patients perhaps that are, candidates for some of these research studies.
I think a big part will be making sure people understand what they're consenting to because , privacy is a big concern that people have about all this data they're creating. But I think it will absolutely make it easier for people to be involved in research studies.
Dr. Maddux: What are the 3 to 5 most important connected health things we should be looking at in kidney care?
Dr. Nash: I would say remote patient monitoring because patients have so many different diseases, the continuation of telehealth and using it not even necessarily for nephrologists but for the whole care team that will really help our patients feel connected, that’s two. Using the data for and using artificial intelligence for predictive values.
Ensuring that payers are going to continue to reimburse for some of these services because that's going to be really important so that the weight of using some of these connected health tools don't go back to the patient.
Dr. Maddux: Any final comments just about what you think the future of connected health is, especially for our company, our field?
Dr. Nash: I think we're going to continue to see patients having higher expectations that we use digital tools. We hear that sometimes now. They want to do more things online. They're becoming more comfortable. I think in ten to 15 to 20 years, we're going to have more patients on home therapies and using these connected, whether it's remote patient monitoring, whether it's wearables and all that.
So I think it's just going to continue to grow. that's the way it's going everywhere in medicine. And I don't think that nephrology or dialysis will be any different.
Dr. Maddux: I'm here today with Dr. Shelley Nash, chief medical information officer for Fresenius Medical Care. Shelley, thanks a lot for giving us some of your insights into connected health and the world that we all live in today. And we'll continue to evolve in the future towards more and more technology use.
Dr. Nash: Thanks, Frank.