Episode 40: It’s Not Telehealth; It’s Healthcare

Jim VanderMey: Well today, we’ve got Joe Brennan, good friend of OST’s and a person that I have great respect for in the digital health space. And so welcome back to our podcast, Joe, to “Ten Thousand Feet.” It’s so good to have you back.

Joe Brennan: Thank you very much for having me. This is always one of the most fun conversations, so thank you.

Jim VanderMey: This is not scripted. We just love the dialogue about telehealth and digital health and the changes that are happening. And Joe, perhaps some of the changes that you’ve gone through recently are worth bringing up, because I think that given the day that we have today, it’d be great to have a conversation about some of the changes that are happening in telehealth from your perspective.

Joe Brennan: Absolutely. Well, I think, just to jump right into it, the global pandemic took something that had real challenges getting off the ground, and it forced telehealth into the public. And I think now that everybody’s had a year to understand what virtual care is and what it can be, it is now a permanent place within care delivery. We are not going back to the way things were prior to COVID-19. And I think that’s forced a lot of us to see, “Okay, well, now that we understand virtual care is a part of care delivery, what is this going to look like?” So I couldn’t be happier that telehealth was able to play such a critical role in a response to a global pandemic. And I think it’s really exciting to what this future holds for, not only just for telehealth, but just care in general. The experience from a patient perspective and utilizing digital tools to remain healthy.

Jim VanderMey: So one of our theses that Joe and I share, and that is fundamental to how we approach this at OST is that, it’s not telehealth, it’s healthcare. And that this is, as Joe just mentioned, just the way that delivery is going to be done in the space.

And Joe, you know, when I first met you, you were working in a large provider organization responsible for the digital health initiative. You moved on to being an independent consultant and we’ve worked together through that process. I have appreciated your contribution to the American telehealth association and your advisory capacities and the awareness that you’ve helped bring to me about legislation and the changes in policy that have been impacting telehealth, but you’ve got a new job. What is it?

Joe Brennan: I do. I am helping out a startup out of Israel called TytoCare. And what Tyto is introducing to the market is a device that can be both consumer or professional, but essentially it’s a diagnostic device that can live in the linen closet or sit with an employer or sit inside a school. It provides seven different tests that someone can take, whether it’s looking inside the ear, looking inside the throat, heart, lung, stomach sounds, there’s a pulse oximeter that attaches to it, and really what it’s doing is taking what was remote patient monitoring, where you had multiple devices and proprietary software, and it’s putting in into something that is all in one and can be utilized by anyone. It doesn’t require a clinician if you don’t choose to do that and works both synchronously and asynchronously. But a much shorter way to say that is it’s extending what the virtual care looks like by adding diagnostic examination for the provider on the other end.

Jim VanderMey: So when we talk about expanding the role of telehealth in adding devices in the home, one of the things that we’ve seen is that if you view this as a technology implementation initiative, which many, many health care organizations are [inaudible] [00:04:51]-[00:04:52] that they miss out. And so we’ve been taking an approach of service design, thinking about the patient experience, and then how the patients and the providers move through both physical in-person interactions, as well as digital interactions, and through patient choice or provider choice, but creating a consistent experience across both digital and physical interaction patterns. What have you been seeing in that space as far as implementations that make for successful experiences for both providers and patients?

Joe Brennan: Well, you hit the nail on the head. This is not a technology play. And those that view it through that lens struggle for scale and adoption. If you build a virtual health program around the patient experience, and then also keep in mind what the provider experience is, using those two as your guide, you will create something that a provider wants to do, and a patient will go to first when something is of concern. So I think if you look at it well, this is just another feature that we’re implementing from the EHR, or you know, this is just a box that we need to check so that we can let our patients know that we do everything that currently other health systems are doing that’s going to fail. And ultimately, without provider buy-in, you’ll be faced with significant challenges of scaling, but once you have the providers bought in and the technology’s in place, then you really need to focus to make sure that when the patient engages with you, that they have a consistent, easy to use experience. And that’s really—when you look at the health systems and the payers who have done telehealth well, that has been their focus.

Jim VanderMey: So how do you know that a provider’s bought in? That’s such a subjective measure.

Joe Brennan: It is, but you can feel it that’s for sure. When you have adoption from a medical group or providers, or you create a hub of providers for a specific use case, the resistance is there when they’re not the champion for what you’re doing. If they’re treating it as just another thing they have to do, it’s really difficult to scale, but you feel it when they are a champion for what they’re doing. You know when they’re bought in, because they’re always looking to, ”How can we improve this?” Or, “I really like this feature, but can you add this?” And, “What if we expand how we do this?” When you start to have that with your providers, you know it’s bought in. The metric is difficult. Obviously, measuring everything is really important. A physician survey is really not going to get to the heart of that, but you know it when it’s there.

Jim VanderMey: Boy, I could go down a couple of different paths on that one, for example, one path that I’m inclined to go towards is what metrics do you have around patient and physician engagement when there is good buy in? Another is, since you know it when you see it, but what are the qualitative metrics that would go alongside those “you know it when you see it” moments. So how do you measure that so that you know that you’re making progress towards good patient and physician engagement?

Joe Brennan: Well, the challenge, because telehealth, even though there is a significant boom, it is still nascent. We are still very early in this. So there aren’t standards across the industry that say, measure these five things and you’ll know whether you’re successful or not, that doesn’t exist yet. And so right now the currency is still encounters. How many encounters did you actually have? And when you get beyond that—understanding where people would have sought care, so that you can attribute cost savings, or what is the convenience factor there?

People often talk about net promoter score from a patient perspective, or if you have some type of other gauge of patient satisfaction, where do those stand? But really the metrics aren’t uniform and everybody measures, not differently, but they measure different things to tell the story that they’re hoping to tell. But I would say that utilization is definitely their total number of encounters. Breaking it down by use case is incredibly helpful to whether it’s, you know, a virtual urgent care for low acuity conditions or it’s a specialty visit. Those things really helpful to separate out so that you understand, but unfortunately we just don’t have a basic set of these are the metrics that we all measure each other against.

Jim VanderMey: Well, and I think that I have encountered a number of organizations where they have not been keeping track of key metrics, and so it becomes maybe a measure of organizational ambivalence, that because they feel like that they have to do it, but they don’t want to do it. And so I’ve used the conversation around how do you know you’re making progress and what metrics are using as a measure of organizational ambivalence? Because the people who are passionate about it are able to talk about the growth and the progress that they’re making very differently than those who are not.

Joe Brennan: And what I’ve found is you get some really good insight if you hang out the marketing department. Understanding the demographics, who’s utilizing the services? How are they hearing about it? What’s triggering them to actually engage? A lot of those metrics you don’t—in healthcare—traditionally use to make business decisions, but pulling some of the data from marketing, it has been incredibly helpful to say, “Okay. Well, we know that this age group and this demographic and this gender and these are where the interests are and we need to put more attention in this area, so it’s been incredibly helpful.

Jim VanderMey: And just frankly, the marketing department has not been a typical technology stakeholder in healthcare, and so partnering with a different part of the organization to access those kinds of metrics, social media, there’s other pieces that are new spaces for a lot of healthcare institutions, because they’re having to access customers or potential customers, not patients.

Joe Brennan: Yeah, it’s difficult to understand how they’re engaging with you based on how many cars drive by a billboard. Those days don’t really help as much as they did in the past. So, I think, now that we have all of these digital tools at our fingertips, utilizing them makes a lot of sense when you’re trying to, not only introduce, but scale something like telehealth.

Jim VanderMey: So, what you’re talking about then is the coordination between digital health and digital marketing. That’s interesting to me. I hadn’t planned on thinking through that, but that just strikes me all of a sudden that the digital marketing capabilities and the digital health capabilities are intrinsically tied together.

Joe Brennan: Especially with—if you’re looking to encourage new patients to your system or encourage new members to your plan—those that don’t already have a relationship with a health system or a primary care provider or an insurance company. If you think about how we behave now, if there is something wrong or there is a concern, normally your first reaction is pull out your phone and put what you’re concerned about into a search bar. And so when you think about a health system’s paid search strategy—may not have been there a few years ago, but now it’s an absolute must-have. And if you know that your low acuity urgent care is really utilized primarily by females, then your campaign’s going to look a little different on social media channels than it would if you were targeting a pediatric population or males in the Medicare Advantage, you know, realm. Utilizing that information is incredibly helpful to say, “Okay. Here are the services we offer, and we’re going to add convenience and access to you,” speaking to specific types of people.

Jim VanderMey: And from the technology implementation standpoint, which is where we typically get involved, that means that we have to create, what I’ll call, low barriers of entry. So from search to the engagement with the telehealth platform to the registration process, and then once they’re a patient, there’s a different expectation for how the health system knows me in that moment versus when they’re a customer or a prospect.

Joe Brennan: Yep, absolutely. And I think you and I have been talking about this for years, but the idea of the digital front door is even—it is so much more important than it was even a year ago. Our behaviors have changed, because of what we’ve all gone through in the last year, and it’s even more important to have an easy pathway, not only into your organization, but when you have patients and members already in, that they can navigate and really understand how to receive the best care.

Jim VanderMey: I had an interesting conversation with one of our clients where I alluded to their poor user experience has been a digital backdoor. What was happening is that people that were in their system were not necessarily using their telehealth platform, so they had inadvertently created the digital backdoor to their competitors.

Joe Brennan: Well, our patience has shrunk to a point where if I can’t connect to something or navigate something, in a short period of time, I’m moving on, because making it easy to use and reliable is paramount.

Jim VanderMey: How does then that translate into a product space like Tyto has, when you’re now talking about putting devices in people’s homes, the complexity barrier and the—what you’re asking the patient to take on for themselves just went up. So how does that work? Because now we’re engaging with a whole set of smart consumer devices.

Joe Brennan: Well, if you think of remote patient monitoring and the way it’s been for the last 15 years, you have devices that speak to some type of box, and then relay that message to a nurse or whoever’s monitoring the software. And that was always a challenge, was, not only the connectivity and setup, but making sure that those devices remain connected and that patients could navigate any technical issues they had, because we know that if you’re challenged multiple times, you’re eventually just going to say, “This is not worth my time. I’m going to move on.”

Companies like Tyto, and I think it’s not just Tyto, many in this market understand that and say, we have to make this as simple as possible so that people use it. It’s great that we sell this device, but it’s really more important that people utilize it. You want them to use it when they buy it and really see the value of what it can bring. And so when Tyto as an example, they pair with your phone or they pair with an iPad, so it’s already an interface that you use multiple times a day you’re very comfortable with, and the pairing process and the connection is something that is pretty seamless, but more importantly, there are tutorials that run if you want them every single time you turn that device on. And so when you think about that helping hand or somebody there to walk with you through the experience,  and again, this isn’t exclusive to Tyto, but it’s incredibly helpful to have something that says, “Okay. You need to do this and then this,” or a—”Make sure that this is on.” Just some type of support so that patients don’t feel like they’re completely alone. And I think in the hospital at home, the device market and everything that we’re looking for at remote patient monitoring, that’s been the challenge is that people have been left on their own to figure these things out until they call an 800 number.

Jim VanderMey: In our consumer connected product work that we do, we talk about the importance of the first five minutes, and that first five-minute engagement pattern oftentimes leads to either the abandonment or the success of the device in the home. And I think that Tyto was doing a good job of addressing that through the mechanisms that you’re describing. Any new announcements since their virtual health summits going on right now?

Joe Brennan: Well, I think, it’s really speaking to where this entire industry is going. So the device makes sense. You can look inside your ear or your throat or hear your heart and lung sounds, but all of those images are then being sent up anonymously into the Cloud. And you have tens of millions of images and sounds that are then put into machine learning. And there is artificial intelligence that is mapping each one of those images, and so they’ll lay an algorithm on top and it’ll pull everything that they’re looking to get from it, and eventually, you will have a triage tool or a support tool for both provider and patient that has learned from millions and millions of images, so that the probability of what it’s suggesting you might have is backed by all of those experiences of everyone else who’s used the device. So people use the term artificial intelligence all the time, and when you pull back the curtain it’s like, well, this is a decision tree, but what Tyto is doing is true machine learning to where that artificial intelligence will get to a point where they can very accurately suggest what might be wrong with you.

Jim VanderMey: That is such an important awareness from a patient privacy standpoint and from a provider standpoint. We’re creating value for the consumer today—it’s through their digital interaction, the remote patient monitoring, but there were capturing data through that interaction that allows us to create new products and services for the future. There’s a thoughtful trade-off then that’s occurring, but that means that Tyto’s gonna be in a position to provide some very strong recommendation engine for low acuity home care interactions or chronic disease state management in the homes, and I’m really looking forward to seeing how that develops. I think that’s going to be an interesting opportunity if that can be brought to fruition. So that’s pretty cool.

One of the things that I’ve been thinking about is that I have to continue to remember that healthcare is a very, very human activity. And the stitching for healthcare comes through our providers and our systems and our interactions as people. The technology can’t do it by itself. Do you feel like—where do you think we’re at as far as our expectation that the tech is going to take care of everything? Because it’s actually easier to implement the tech than it is to change the systems.

Joe Brennan: I agree with you completely. I think, if there is any good that comes from what we’ve all experienced for the last 12, 13 months is that this isn’t a lesser than experience, this isn’t a less than care offering, and because people were forced to understand what telehealth is, and potentially utilize it because it was the only option, I think we’re getting closer to say, “Oh, well, you know what? Actually, I did have a very quality encounter with a provider and they did answer the questions that I had, and I feel like I did receive the care that I need.” Because at the end of the day, this is exactly as you put it—it’s a human experience. And if you’re dealing with a chat bot and there’s no personal touch to it, and it just feels very cold and unconnected, I think people wouldn’t be bought in, but what we’re finding, not only through telehealth, but even the encounters that we have with family and friends virtually, we were forced into this experiment that showing that you can still have the humanity, even if you’re not sharing within the same room.

Jim VanderMey: And I think that for some types of care, for example, certain behavioral health interactions that the telehealth platform is actually superior, because of issues of accessibility, of timeliness, of, you know, if you have someone who’s in a moment of need with a—needed an access to a mental health provider, the digital platforms are definitely superior in some respects to trying to get to approximate provider physically.

Joe Brennan: It was always a great use case, but I think the pandemic really exposed why it’s so important. I’ve had multiple conversations with behavioral health clinicians that say, “The majority of my practice moving forward will be virtual, simply for the fact that my patients prefer it.” And again, being forced to experience what it is and be comfortable with what telehealth is, because it’s your only option, I think people really found out, “Oh, this is not only viable, but it’s now preferred.” Our behaviors have changed.

Jim VanderMey: Yeah. So Joe, as you talk about Tyto, with the diagnostic tools in the home, what’s next beyond the instrumentation side?

Joe Brennan: Well, I think the next iteration of what this looks like, and we learned this again because of COVID, is testing in the home. So lab work in the home. What Tyto’s introducing at the end of this calendar year is a device that connects just like the otoscope does and the stethoscope, but it will allow you to do labs inside your home. And so you can take a swab of the inside of your cheek, put it into the device, and in 15 minutes you have results on flu A, B, COVID-19, strep, and then eventually moving into next year, not only saliva, but urine. So when you think about the impact of in the home lab testing, it’s pretty significant. And the devices also live with employers when urine tests are needed. And when you think about the impact that this would have in schools, it’s pretty significant. So in addition to heart and lung sounds, and looking inside the throat, you can now do up to 25 labs within the home. So that is the next step of what this will look like.

Jim VanderMey: So I have so many questions that come off of that. The first off, there have been some highly public promises made by other health tech companies about the ability to do testing outside of traditional clinical environments. What’s the FDA cycle for this and is it, you know, when we’re in a world where we talk about going to our local pharmacy for test results and having to get swab before going on trips and so on and so forth, that’s a huge, huge, impact both personally and into the medical community, so is that real?

Joe Brennan: It is. Unfortunately, Elizabeth Holmes is—changed our views on testing, but this is real. If you look at the success of Everlywell and companies like that already, where you get a kit sent to you and then you send it back, or there is our results within home, the industry’s already progressing in that direction. And unfortunately, Theranos has left a very bad taste in people’s mouths, but this is real and it is coming. I think, again, and I know that I keep mentioning this, but we not only learned a lot, but we moved much further than we would have had COVID-19 not shown up. And there were so many people racing to get onsite testing and in-home testing that it really expedited the process of development for many of these tests.

Jim VanderMey: And that’s, what I’ll say, is the exciting upside of a global pandemic.

Joe Brennan: There has to be something, right?

Jim VanderMey: That’s right. Well, and that’s a good reminder that with all of our work in health IT and telehealth and digital health, that this is a human system supported by technology, not a technology system supported by humans. And I want to do everything we can to improve the humanity of healthcare and improve the accessibility of healthcare through digital health. I know you’re on that same path with me, Joe, and look forward to our future conversations, so thanks for being with us today.

Lizzie Williams: OST, changing how the world connects together.