The health care of tomorrow? International learning on community, technology, and avoiding digital exclusion

Key:

• AC: Anna Charles
• HC: Dr Henry Chung
• ST: Dr Steve Tierney

AC:         Hello and welcome to The King’s Fund podcast where we talk about the big issues and ideas in health and care.  I’m Anna Charles, Senior Advisor to the Chief Executive here at The King’s Fund and your host for this episode.  Now, we may be stuck working from our bedrooms and our kitchen tables, but that isn’t stopping us here at the Kings Fund from touring the world, albeit virtually to find out what we can learn from healthcare systems abroad.  With the support of NHS England and NHS Improvement we’ve recently been connecting integrated care systems in England with health systems from across the globe to talk about the challenges and opportunities they’re facing and share ideas on the future of health and care.  Now a lot of changes have clearly taken place to the way care is delivered over the past year, including different ways of supporting people at home and working with communities and a massive shift to virtual consultations and using digital technologies.  We’re not alone in the UK in seeing those shifts.  So many health systems around the world have been making similar changes and actually some of them started on those change journeys long before COVID-19 came along.  So, today we’ll be looking at two very different systems that have worked over many years to change the way they deliver healthcare and work with their local communities, focusing particularly on how they’ve used digital technologies to do that.  Importantly we’ll be considering what their experiences can teach us about how local health and care systems here in England might be able to respond to some of the challenges they’re facing and improve the health and wellbeing of their communities.  So, I’m joined by two guests, Dr Steve Tierney joining us from Anchorage in Alaska and Dr Henry Chung joining us from New York.  Now Steve is a GP and Senior Medical Director for Quality Improvement, and Chief Medical Informatics Officer at Southcentral Foundation and Henry is a psychiatrist and also Vice-President and Chief Medical Officer for the Montefiore health system.  So, welcome both of you to the podcast, it’s really great to have you with us.  Many people listening won’t know much if anything about your two health systems so I wonder if we can just start by setting the scene.  Henry, starting with you, can you tell us a bit about the Montefiore health system?  

HC:          Sure, the health system is largely based in the northern part of New York city, now expanding its territory into what we call the Hudson Valley, so some of the counties north of New York city.  But its roots are in the Bronx county of New York city which unfortunately has had the decades old reputation of being one of the most health deprived and most challenging socioeconomic areas within all of New York State.  I always like to quote this number to give people a sense.  So, we have in the United States a programme called Medicaid, which means essentially publicly supported healthcare and you have to qualify generally speaking at the poverty levels.  In the Bronx county, for which Montefiore started and is really largely responsible, we have 1.8 million residents in that county.  50% of the county is on Medicaid.  So, that really tells you the kinds of challenges that we have.  It’s largely a black and brown community that we serve.  We have tried over the years many innovative approaches.  You may have heard about some of the work that we’ve done and what we call in the United States accountable care, where we take some financial risk in return for trying to improve the quality of care for the community.  So, we’ve been a leader in that particular space in the United States and in New York city for quite a while.  Strong social justice and equity mission.  Let me stop there. 

AC:         Thanks and we’ll come back to explore some of those themes that you’ve talked about, later.  Now Steve, you’re also in the States but Alaska I think is more than 4,000 miles away from New York.  It’s a pretty different setting.  I know we were talking earlier, the temperatures at the moment are pretty different.  It’s a different population.  So, can you briefly set the scene for us around your system.                   

ST:           Yes, thank you.  We care for 70,000 Alaskan native American Indian customer owners in our sort of geographic area.  While we’re based in Anchorage, which is our largest sort of municipality, our customers are spread out over a geographic area that would stretch from Miami to San Francisco.  So, we have clinics that are I would say … our definition of rural is quite a bit different than most of the world in that you are living on an island with maybe 150 other people, and we still have to deliver what we would call first world, on time, accurate, high quality care.  But it means though that we had to think about care delivery differently, to think about what were the events we were trying to accomplish and divorce that completely from what were the usual workflows.

AC:         One of the aspects Steve, that is often talked about in relation to your system of care which I think is often referred to as the Nuka system of care, is the way that you bring different staff together to meet people’s needs through a multidisciplinary approach and the approach you’ve developed to that over many years.  So, can you say a bit about what that looks like in practice and what that means for patients in your system and for staff working in your system as well.               

ST:           It’s interesting.  As we redesigned the care experience we actually tried to borrow from what we would call very successful retail or gig economy models.  So, we had said how does Amazon out-compete Sears?  Well what Amazon did was sell you the … whatever it is that you were shopping for at a lower price, but how they got to that was to attack their infrastructure and overhead costs.  So, what we did was eliminate all unnecessary infrastructure where possible to be able to say, the shortest number of events, tasks or touches needs to occur for the final event to happen.  So, for instance if you’re on a tiny island in the middle of the Bering Sea, and you need a prescription because you’re ill that morning, we would say the final event is, you get an accurate diagnosis and a prescription.  So, what we do is wire our local practitioners out there who would be essentially like EMTs, we call them health aids, and we’d build a medicine kiosk that looks like a candy machine, where the health aid would collaborate with the … in Anchorage, in the urban area … practitioner who would legally make the diagnosis, queue the prescription to be written and then the pharmacist would drop it electronically remotely from 1,000 miles away.  But what they did for us was open up a whole host of new opportunities.  Why would we maintain two building structures or front desk processes when we could say, why don’t we just blend them together to say the psychiatrist and the mental health counsellor, will coexist in the same physical space as the GP and the pharmacist and the dietitian, or the home visiting team, where they would work collaboratively to say we work as a collective work unit.  We occupy the same space, and we care for the same identified number of people and so we will adjust in real time where there will be no referral, there will simply be, please join me in this room.  Now during COVID we had to adapt quite dramatically to that and what we actually did was leverage Microsoft Teams to have the same sort of fluid interaction environment where we would say, let’s just ring up our teammate who we would normally go and physically get, and then say would you chat with the person I’m having a video interaction with, because it looks like they may have some signs and symptoms of depression and we want to bring you in on demand.  But there will be no separate queue, separate referral, separate paperwork, separate transfer, and separate sort of physical building to maintain. 

AC:         So interesting.  One of the things I did want to talk about as well was around supporting self-management.  Because of course one of the ambitions that’s often talked about in terms of how health and care systems need to change is the idea of moving away from a paternalistic relationship where people are passive recipients of services and doing as I said, much more to empower people to manage their own health and wellbeing.  Henry, I know in Montefiore you’ve placed a big emphasis on behavioural health, and I wonder if you can tell us a bit about what that means and the kinds of changes that you’ve made around that. 

HC:          Absolutely.  I mean let’s just talk about kind of the example that Steve just brought up a second ago about the person who has depression, generally speaking sees their GP, their general practitioner and the general practitioner in our community takes a large amount of responsibility for identifying the depression and then treating the depression.  There’s still tremendous stigma in our community for black and brown people to walk into a formal mental health facility.  So, most of it occurs there.  But here’s the challenge.  The best practices for depression generally requires monthly visits for the person with depression at a minimum, particularly during the acute stage when you are treating them with medications.  Or if not medications a lot of support.  Well here’s where the challenge comes in, which is that in our area there’s absolutely no way that primary care practitioners can easily schedule people back to come in monthly when their panel sizes are as large as they are and when they have spaces open for walk in access on a daily basis.  So, the idea of bringing people back on a monthly basis, at least the first four months for the treatment of depression is unlikely.  Here’s where we use technology to empower if you will the client, the patient with a care management relationship that would supplement and augment what the GP could do.  So, we provided for three years now, a smartphone application that was given to our patients, which gave them essentially nine to five, 9 am to 5 pm, text contact with a care manager whose responsibility it was to help with adherence to the treatment plan, resolve any concerns about the care plan that the patients may have.  I’m worried about taking this medication, I’m worried about this diagnosis, what does this mean for me and my work or me and my family.  Getting them through those early humps and then focusing on these incredibly evidence based but under utilised aspects of self-management which generally speaking work for most chronic conditions.  How do you get people to start increasing their activity for exercise?  How do you start decreasing isolation and improving socialisation?  How do you work on sleep hygiene?  It’s through this smartphone app which has patient educational materials, has ways of interacting with the client using the care management relationship, has ways of getting measurement seamlessly to get those depression scores, those anxiety scores that drive treatment change, between primary care visits.  By doing all of those things we’ve been able to basically improve our outcomes tremendously and triple our rate of staying in touch with patients during their behavioural health treatment with their GP.  So, we’ve been incredibly excited about it and that’s only expanded since the pandemic.

AC:         Steve, what about the Nuka system?  Are you bringing behavioural health into your approach in a similar way and if so is technology playing a role in supporting that?  What does it look like for you?  

ST:           Well we had brought some behavioural health, essentially master’s level clinicians, physically into the space with the GPs in 2005.  So, we’ve been physically operating as a collaborative team for a long time.  When we were actually on paper charts we were doing this.  So, well before technology.  But what has changed is we’ve gone further, and this is where I think Henry’s hit on something interesting, is smartphone technology.  So, our ability to adapt as a system takes years to turn workflows … when we have recognised when pressed it shouldn’t take that long.  We actually can adapt.  When we deconstructed our prior system we said, if you’re a GP, 85% of all the orders for prescriptions and medications and labs and x-rays are repeats.  So, the vast majority of the work that you do is refilling things with existing plans.  What we had to do is to say that occupies the majority of the bandwidth and prevents the opportunity to intervene with new or rapidly changing.  So, we had to divert that work into a larger capacity but lower cost infrastructure.  So, we built essentially support clinics with medical assistance who would draw labs, do injections, check vitals, etc., feed that information stream back to the nurse case manager and GP practitioners and if all was stable and well, never warranted a visit directly.  But what that did is open the door for the bandwidth to say, but as soon as it looked somewhat not normal, or felt different or was uncomfortable, well that warranted the ability for us to deliver an almost I would say real time visit.  Then we had to rethink what was a visit.  Was a visit a chat on the phone?  Was a visit a text?  Was a visit a real time office visit?  The answer is it should be potentially all three.  So, I think we’re at this point where we realised we were furiously creating work for ourselves to do the very new and acute with the same sort of intensity as the simple and mundane and repetitive.  What we have to realise is we can’t continue to survive having the same level of intense workflow to refill an existing med that’s been in place for ten years.  Or do a new, undiagnosed condition.  We have to shift that around.  But while we’re at it, why would we not shift all of it around?  Why would we not say, this should be as fluid as on Microsoft Teams, the app is on my phone, the people who are chatting to me today are the people who I work with professionally, why wouldn’t that also be the customers themselves? 

AC:         I’m so struck listening to both of you about how much you’re describing these new technologies, new ways of delivering services, but actually it’s about how the workflow changes around that and how the ways of working for staff adapt around that, that is more important than the technologies in and of themselves.  A challenge that’s often raised in terms of bringing in new ways of delivering care is to make sure that they don’t just work for certain groups of the population, but they’re accessible, effective, get good outcomes for everyone in the community.  I know already here there is some evidence that certain groups have been more likely for example to have a negative experience of virtual consultations during COVID than others, and a key concern that’s now coming up as well, if we keep some of those changes in the longer term, might there be issues around digital exclusion, the potential to create a wide and health inequalities.  So, Henry, coming to you first, obviously you’ve mentioned a key focus of the Montefiore system is how you work with deprived communities, a large part of your population, so how do you make sure that changes you’re making to your delivery models are working for people and how are you addressing the issue of digital exclusion if that is coming up for you? 

HC:          Yeah those are great issues to ponder.  First of all at the height of the pandemic technology included phone based care and that was not unheard of, but to think about that for a second, it meant that if people didn’t have video … most people have phones, cell phones certainly, and communicating with their GP or communicating with their mental health practitioner was as simple as a phone call.  Now, one could argue that if you have an ongoing relationship with someone and you kind of know them fairly well or intermittently well, a phone based relationship is probably not bad.  If a phone based relationship can be enhanced with the kinds of things that Steve talked about which I’m excited, where the routine things like getting blood work, getting a sense of if anything has changed with the client or with the patient, if you get those datapoints routinely.  Then I think phone based care actually is quite good, but that’s the issue.  The issue is, has the system changed enough to basically say I don’t need to do a physical exam on someone year after year after year, if things are pretty much the same.  That is still not the norm in terms of American based practice.  It is still getting people in.  Now, shift ahead to sort of more video based technologies where people think that’s a version of more complete care, when you start moving in that direction there’s absolutely no question that for our communities access to digital video based technologies are a real challenge because of cost and even in our urban environment, consistent bandwidth.  There is the chance of exclusion and that explains why as soon as we got past the search, and we began to see patients again in person there was a sudden rush and most of our GP clinics are back to about 85% of previous in person visits.  We had thought maybe that would not be the case, but we’re getting up there.  It’s because the desire to get back in the room and also some clients see the digital piece as being perhaps not as … maybe not as accurate for them.  There are concerns about quality, not having the touch.  I think that means a lot to some of our clients.  So, yeah I think that’s an ongoing challenge and as you know if you’ve been following US politics, one of the big issues that the new administration is looking at is this notion of a more complete sense of what infrastructure improvement means.  It certainly now includes improvement of broadband but also as an equity issue, maybe subsidising the cost of these technologies which is something that we have not thought about before. 

AC:         Steve, any reflections from you on that, making these new ways of delivering care work for all parts of the community? 

ST:           Well this is when I think about change.  I would say defending our current approach, as Henry describes it in the United States, is clearly not working at all for a large number of groups in the community.  So, saying we may exclude some people by changing to a new way of interacting, well it’s already excluding vast numbers of people today.  There’s no such thing as an abrupt, today we’re doing it one way, tomorrow we’re doing it another way.  I call this is the Netflix Blockbuster shift.  Netflix came into being and it was ten years before Blockbuster realised that it was no longer a relevant model.  So, this will be at least a decade long transition.  Anything new that you build you want to build for a future state.  So, as we move forward I think we want to recognise that we have a younger demographic who will need care, who will demand a different way of interacting and then say, well the choice should be you can text, you can audio only, you can audio video or you can do real time in person.  Building it to assume there is only one way forward is not a rational premise.  So, how do we begin to have a system that can pivot at a moment’s notice as the conditions on the ground change?  What we’ve learned is we’re going to miss a lot of people if we don’t have something that can fluidly adapt as the world changes in real time.

HC:          I really want to chime in on Steve’s point and just build on this.  There is a bit of this sort of dichotomy along age that we see.  I would say the baby boomer population and above, where even though they’re digitally savvy the issue is do they feel like they’re getting the same quality?  We’re trying an experiment that I think will get us over the hump.  I think that the idea of doing remote patient monitoring is actually going to make a difference in converting a lot of these folks over into digital visits.  The reason is the following: there is nothing more accurate when you’re treating someone with chronic conditions right, so think baby boomers, hypertension, diabetes, that kind of thing.  You say to them look, I know you when you come into see me in my office once every two or three months, we get these values, and it looks like this and then we have to do something about it.  But what’s really more accurate is, how is your blood pressure trending in-between the visits.  How are your blood sugars trending in-between the visits?  Now, if I can get access to that without you having to go to a lab and that comes right into our electronics systems for remote patient monitoring and through Bluetooth devices, I think that’s going to be a big conversion factor.

AC:         So, Steve, whenever I hear anyone from the Nuka system speak I’m always really struck by how different the language is that you use around how you work with your communities.  So, you have this sense of community ownership, or I think customer ownership is the phrase you use and really working partnership.  So, for you how do you work with your communities around changes to your making to the way you deliver care? 

ST:           Early on we would go through focus groups and getting feedback and doing surveys and things like that and we recognise that to do change as rapidly as we often needed to do change, it created such a time delay that it was really difficult.  So, probably about 20 years ago we shifted our strategy.  We said one of the operational imperatives for the organisation would be to employ the community.  So, we look as a benchmark measure, we want to have … and today we have about 65% of the entire workforce is from the community that we serve.  So, they both work here, and they have a chart here.  Our entire board is all community members, and all have charts here with us.  But what we had to do is to say that’s not just something people will wake up and say, I’m going to wake up and I’m going to work for the Southcentral Foundation because they were graduated from high school, they didn’t know what career they wanted.  They needed new skills.  So, we actually had to build an institute to actually train and recruit them.  So, as an example we say, if you’ve graduated from high school or you have a GED and you’re part of the native community and you don’t have a job, we will train you and pay you while we train you, for 12 weeks.  We will teach you Microsoft, we will teach you computer skills, we will teach you office skills.  For 12 weeks we’ll pay you and then you’ll leave, we’ll give you a certificate for that training.  Now if you want to apply for a job here at the end of that, that would be great.  But if no, if you want to work someplace else, that’s fine too.  We’re not going to make it contingent upon taking your money for the training that you work for us.  Now we also said, once you do work for us we’re going to give you a clear progression of a career ladder where you could say, well in five years I could become an admin three.  I could become a programme coordinator.  I could become a manager over time.  Or I could go more the medical track or more the infrastructure support track into data and IT and things like that.  So, we create an opportunity where we say if we hire you when you’re 18 years old, we want to have a viable means of employing you until you retire.  So, when we ask how’s it going for the community, we are the community.

AC:         That’s such a powerfully different way of thinking about the relationship between the health system and its community.  I think when people talk about health and care organisations acting as anchor institutions or anchor systems, that’s a description of what that actually looks like in practice.  So, stepping back a little it seems as though your organisations both work from a really strong values base.  Now of course lots of organisations have lists of values but don’t necessarily live those values and everything they do, but that feels different for your organisations.  So, I wonder if you could just briefly say a bit about the values that underpin your systems and how they’re embedded.  Henry.

HC:          I think the motto of your mission really has always included a sense of social justice and equity.  We very much invest in our community through making sure that we have employment opportunities in the way that Steve just described.  But I also think of our place in our school health system where Montefiore basically has 30 clinics located within our middle schools and our high schools and what impact that has on not only providing care for folks right where they largely go in the institutions that really surround their daily lives.  But also as it relates to their role modelling and seeing the kinds of people that we have at Montefiore who look like them and they can then see that this is a possibility for them.  So, I would say that pretty much reflects our real values. 

AC:         I’d like to end by looking to the future.  So, lots of changes have happened over the past year or so, what do you hope health systems around the world will learn from the experience we’ve had and what changes would you like to see health and care systems take from that into the future? 

HC:          There’s what I’d like to see and then realistically the way that care is reimbursed here in the United States makes it more complicated.  But really what I’d like to see looking into the future is a lot more consumer directed ways for them to obtain the healthcare that they want at the time that they want the healthcare.  I don’t believe we’re there yet, but I’d like for us to get there.  Ways would be for example, allowing our consumers to interact through consumer portals that not only get them in touch with a provider but also provides them with a level of information in which they can act positively for themselves.  So, if you look at most things, at least the literature I’m familiar with in psychiatry and mental health, I would estimate that at lease 50% to 60% are things that they can actually do themselves if we provided them the right kinds of educational materially.  I mean really engaging stuff.  I think in healthcare we’re not there yet.  We haven’t provided that Netflix type experience, but that’s what I’m looking forward to, for me as well. 

AC:         Steve.

ST:           We spend tens of billions of dollars a year on things like information exchanges, on sending records to each other across the country, back and forth, with tremendous time delays and really in a lot of cases sending a lot of non-value added sort of fluff with the records that we do transfer.  We spend tens of billions … I may go so far as to say as much as close to a trillion a year on this sort of activity of managing information.  Yet you have a Facebook profile, you’ve got a Twitter profile, you’ve got a TikTok profile, why wouldn’t you have a health profile?  Why wouldn’t you own your own medical records and if you’re seeing Henry in New York you would simply pull out your smartphone and say, as I appoint with you I’m going to allow you, Henry, to see all of my health information for the purpose of this encounter.  Then as I travel on my vacation to Alaska and I see Steve, the same for Steve.  Well the person who holds this is themselves.  The person who shares it is themselves.  The work Henry and I have to do to trade this information back and forth is none.  I think as we move forward we need to think about what is the cost and what is the benefit and what’s the loss of that work that we currently do as we build these monstrous, behemoth of information exchanges that honestly no-one really looks at.  Because when you’re a GP and you’re trying to see your customers per day, you don’t have an hour to surf on the web to look at all the other places they may have gone to, you just don’t.  But meanwhile we spend billions of dollars maintaining them.  Why would we do that?  Why don’t we just say, I just need to see your recent labs, your recent vaccinations, your allergies, your meds and your encounters and your procedures.  That’s all I need to do.  If you can give them to me then we’re good and you save me a tremendous amount of time.

AC:         Well you’ve both left me with lots to think about for what the future might hold, and I hope our listeners as well.  Thank you both so much for joining me.  That’s it from us.  If you’re interested in learning more about different international systems then you might like to sign up to our monthly integrated care bulletin or watch the short interviews on our website of leaders from health systems around the world, sharing insights and ideas from their systems.  There’s a link in the show notes for both of those.  We’d also love you to subscribe rate review us on apple podcasts or wherever else you get your podcasts.  Thank you this time to our supporters for this episode, NHS England, and NHS Improvement and of course thanks as always to our podcast team, our producer Ian Ford and our colleagues Ben Collins, Deena Maggs, Nicola Walsh and Helen McKenna for their advice and research support.  Finally, thanks to you for listening, we hope you can join us next time.