UP CLOSE | The future of health care: How the pandemic ushered a new era of innovation at YNHHS
Though the Yale New Haven Health System was hit hard by the pandemic, it moved towards a more digital future as it adapted to fight the coronavirus. According to health system officials, many of the changes instituted will last for long after the pandemic has passed.
Physicians have argued that health care in the 21st century will be divided into two separate eras: pre- and post-COVID-19 pandemic. Though experts have reason to believe that the coronavirus might linger for a while, the way its arrival impacted health systems across the globe was dramatic and destructive. At the same time, it also pushed health care professionals to seek pragmatic yet innovative solutions to address the herculean challenges that came with the coronavirus.
From repurposing masks to building treatment protocols that were used by physicians worldwide, innovation was central to the Yale New Haven Health System’s operations throughout the pandemic.
In the past, the health care industry has been slow to adapt to new technologies. According to a 2017 study commissioned by Virtusa, an information technology company, health care lags approximately a decade behind other industries when it comes to innovation. This is largely due to regulatory barriers, such as extensive safety evaluations and risk assessments, that must be surpassed before new developments can be used in patient care — that is, under normal circumstances.
When the World Health Organization officially declared the pandemic in March of last year, the FDA created special emergency programs, such as the Coronavirus Treatment Acceleration Program, and participated in initiatives meant to speed up the development of new diagnostic methods, such as the COVID-19 Diagnostics Evidence Accelerator. Those changes allowed the American health care industry to innovate quicker in the face of the pandemic.
In more ways than one, the pandemic also catalyzed the digitalization of health care. From telehealth consults to the use of new technology to remotely monitor patients with chronic conditions, the pandemic has pushed the Yale New Haven Health System towards a more technologically advanced model of health care.
“It accelerated our adoption of telehealth like nothing else could have,” L. Scott Sussman, physician executive director for telehealth at YNHHS and Yale Medicine, told the News. “Along with that came the need to scale things and make sure that we had patient-friendly ways for accessing health care, so we went through different iterations of software, we created different workflows, we set up teams. … [Our] goal was to make it easy for patients to access this technology.”
In interviews with the News, biomedical scientists, Yale alumni, YNHHS physicians and administrators said that even though innovation was already a part of the Yale New Haven Health system, the pandemic has expedited its entry into a new era — one that leverages the advantages of technological developments and telehealth modalities to improve patient care.
“It accelerated our adoption of telehealth like nothing else could have. Along with that came the need to scale things and make sure that we had patient-friendly ways for accessing health care, so we went through different iterations of software, we created different workflows, we set up teams. … [Our] goal was to make it easy for patients to access this technology.”
—L. Scott Sussman, physician executive director for telehealth at YNHHS and Yale Medicine
Innovating under lockdown
In the beginning of the pandemic, Lisa Lattanza, chief of orthopaedics and rehabilitation at YNHHS, had to cancel her operations. As an orthopedic surgeon, most of her cases were considered elective, which meant that, initially, she would have to hunker down at home and wait out the restrictions on those surgeries.
But despite not being able to act in the area of her training, she was summoned by the same call to action that doctors from all specialties felt pressed to respond to. The idea of using her experience to contribute to a then-limited, but nevertheless growing, arsenal of COVID-related knowledge and medical strategies made her excited to join the battle against the coronavirus.
Lattanza was part of a multidisciplinary team of physicians, scientists and engineers that were recruited at the beginning of the pandemic to be a part of CHIME — Yale’s Coalition for Health Innovations in Medical Emergencies.
“I wanted to do something to help,” she said. “I’m not in a specialty that is very much help with taking care of COVID patients, as an orthopedic surgeon, but I am and have been in an innovative space within orthopedics and 3D technology for about a decade.”
The CHIME group, Lattanza said, began their pursuits by trying to solve the issue of mask scarcity. From testing whether they could 3D-print masks that were as safe and effective as N95s — the gold standard for viral protection, which filter out up to 95 percent of small molecules that hover in the air — to trying to find urgent solutions to ventilator shortages, the team brought together a wide range of scientific expertise to address what were then the most pressing problems.
“[The role of health innovation] has been shifting and evolving based on what the pandemic needs were,” Lattanza said. “Initially it was pretty rudimentary, it was getting masks and gowns and ventilators and things like that for patient care, and then I think the technology advancements really evolved.”
“Some things that have really been hurdles for the health system prior to the pandemic became necessities, and that was telehealth and how we had to transition in seeing patients. Now that’s become a really big part of certain people’s practice.”
—Lisa Lattanza, chief of orthopaedics and rehabilitation at YNHHS
Although CHIME’s activities have since slowed down as supply shortages were remedied, the spirit of innovation remains alive within the scientific community and health care industry.
While this spirit of innovation occurred out of necessity, YNHHS later realized that a more long-term investment into the future of patient consultations could be advantageous. Telehealth, which was rarely used within YNHHS in February 2020 according to Sussman, is now widely used for primary care and specialty consultations in the system.
While in February of last year YNHHS had completed 39 video visits, Sussman said, in February of 2021 alone, 45,224 video visits were completed system-wide. Now, the health system completes in only 10 minutes the same amount of telehealth consults they used to perform in a month.
“Some things that have really been hurdles for the health system prior to the pandemic became necessities, and that was telehealth and how we had to transition in seeing patients,” Lattanza said. “Now that’s become a really big part of certain people’s practice.”
As the outside world had to shut down to curb the spread of the coronavirus, health care workers were forced to find an effective way to see their patients beyond hospital walls. Though there are many components to patient care that are not as adaptable to platforms like Zoom, including hands-on observations that are characteristic of physical exams, physicians circumvented these limitations by getting creative.
“If someone is complaining of abdominal pain, you might ask them to jump up and down, and if they are able to do that and maybe they even laugh, because it’s a silly thing to ask someone to do, they are less likely to have something like acute appendicitis, because if they have acute appendicitis it hurts to move and they will not do it,” Sussman said.
Another procedure that was hard to adapt was that of throat inspections. This type of exam would typically take place during an in-person visit and would involve inserting a 90-degree telescope into a patient’s larynx, upon which a light would be shone to reflect an image of the throat using a small mirror. At home, however, doctors have developed new protocols whereby they instruct patients to do a similar set up using their phone’s flashlight, according to Sussman.
Other techniques, though less improvisational in nature, are equally as exciting, Sussman said. Digital tools are being sent to patients with chronic illnesses like diabetes and hypertension, and are being used on a more long-term basis to monitor their clinical states remotely.
“Another thing that we’re really excited about that’s newer is we’re using digital stethoscopes for select scheduled cardiology appointments,” Sussman said. “The patient would receive a digital stethoscope that they could put over their heart or lungs, and that information would be transmitted electronically to the physician so that they could have that information as part of the physical exam.”
From an infectious transmission standpoint, YNHHS Medical Director of Infection Prevention Richard Martinello said in an interview with the News that, depending on the gravity of a patient’s symptoms, avoiding in-hospital visits and instead consulting with physicians through telehealth could prevent infections that are acquired in waiting rooms, for example. According to the CDC, one in every 31 patients who enter a hospital, for example, may leave with a “health care-associated” infection.
But, as an infectious disease specialist, Martinello also explained that he worries about how telehealth could affect antimicrobial stewardship — a concerted effort by physicians to avoid unnecessary prescriptions of antibiotics. Without conducting a physical exam, some doctors might not be able to fully ascertain what a patient has and could overshoot antibiotic prescriptions, which could give rise to resistant bacterial strains if it becomes a widespread practice.
Even though telehealth might not be perfect right now, both Martinello and Lattanza pointed out that a change in the mindset of physicians and how they approach patient care through this modality will likely ensue after the pandemic, which could bring important developments to the area that make it even more comprehensive.
Though emergency medical needs should continue to be tended to in an in-person setting, Sussman explained, even after the pandemic, routine consults or periodical checkups could feasibly be transferred to an online format.
“Hospitals may one day be emergency departments, operating rooms and ICUs,” Sussman said.
Significant innovation is also taking place within the realm of remote patient monitoring. Even patients who are seen in an ambulatory setting for an emergency, for example, can leave with devices that enable their physicians to check in on their clinical state, if necessary.
“We can send a patient home with a digitally connected blood pressure cuff, a scale or a glucose monitor, and we’re able to get that information and provide care at a distance,” Sussman said.
For patients who already have chronic diseases, remote monitoring advancements that had already been in the works prior to the pandemic became even more important.
“Those patients … were actually at a great advantage because we could see everything that was going on remotely and they didn’t have to come in. If they had a question about anything we could go and look at the recordings and tell them what was happening with their brain waves.”
—Imran Quraishi, assistant professor of neurology
At the Yale Comprehensive Epilepsy Center, epilepsy patients who had responsive neurostimulation devices — which are surgically implanted into the brain to monitor brain waves and respond to activity to prevent seizures — could be remotely monitored by their physicians, Imran Quraishi, assistant professor of neurology, told the News.
“Those patients … were actually at a great advantage because we could see everything that was going on remotely and they didn’t have to come in,” Quraishi said. “If they had a question about anything we could go and look at the recordings and tell them what was happening with their brain waves.”
Other technology, such as Percept PC — a deep-brain stimulation device that is used in the treatment of drug-resistant epilepsy patients — comes with a programmer, which is like an app and can be accessed in Samsung cellphones, Quraishi explained. These programmers allow patients to check in on their devices’ battery lives and, in some cases, even adjust their therapy.
According to a press release issued by YNHHS on Mar. 16, the Yale New Haven Children’s Hospital has also partnered with DreaMed Diabetes, a medical device software company based in Israel, to test a new artificial intelligence device, called Advisor Pro. The tool could be used in the future to treat pediatric diabetes patients by tabulating changes to their blood glucose levels and automatically adjusting how much insulin they need to inject themselves with.
Though clinical tests will be conducted with 100 diabetes patients at the children’s hospital over the next few months, as described in the press release, this device should also allow for doctors to monitor their patients’ glucose levels virtually, eliminating the need for them to come in for consults every time a checkup should be made.
“Having our software utilized as a strategy that allows for both virtual and in-person visits is a necessity in the era of COVID-19 and the future of care,” Eran Atlas, co-founder and CEO of DreaMed Diabetes, said in a YNHHS press release.
The lifesaving power of telehealth in medical emergencies
Providing a means for people to request urgent consults at their fingertips is yet another way in which telehealth is contributing to patients’ well-being. In the case of strokes, for example, which are time-sensitive medical emergencies, YNHHS offers a service called TeleStroke.
“With TeleStroke, we have stroke neurologists who are available 24 hours a day for consults, and they perform those at over 15 different locations across Connecticut and into Rhode Island,” Sussman said in an interview with the News. “If someone is suspected of having a stroke, a consult is initiated and within minutes a stroke neurologist is able to get on a video visit and help with diagnosis and also direct treatment.”
According to the American Stroke Association’s guidelines, for patients suffering a stroke, timely treatment can be crucial. It is estimated that approximately 2 million neurons are lost for every minute of delay in restoring blood flow in the brain of someone who has suffered a stroke. “Door to needle” time — or how long it takes to get to a hospital, be correctly diagnosed and undergo proper treatment — can have a decisive impact on whether or not a stroke patient will ever walk, talk or even wake up again.
Though YNHHS’s TeleStroke program has been around for almost a decade, Sussman said, it became particularly important during the pandemic.
“It has literally impacted the lives of thousands of patients,” Sussman said. “Over 1,400 in 2020 alone were able to receive the care from Yale’s stroke neurologists. Otherwise, they might not have had positive outcomes.”
Telehealth in the ICU
Though YNHHS has been using teleICU — real-time audiovisual monitoring of patients in the intensive care unit — for almost five years now, according to Sussman, the advantages of this modality of care have become particularly evident during the pandemic. At Yale New Haven Hospital, for example, patient rooms in the ICU have cutting edge cameras so doctors can check in on their patients, Sussman said. This proved to be crucial with COVID-19 ICU patients, as the health care workers treating them can limit their exposure to the virus.
“They use high-definition cameras so that they can zoom in and even count somebody’s eyelashes, that’s how good the cameras are,” Sussman said.
Thanks to this platform, nurses and doctors also do not need to enter patients’ rooms to check on their vitals — they are registered in real-time and updated minute-to-minute in their monitoring station in the ICU. This allows health care professionals to react quickly to any urgent changes, despite not being present with the patient at first, according to Sussman.
Doctors and nurses thus do not need to re-don their full personal protective equipment every time they need to check on a COVID-19 patient. They can easily keep tabs on all of them at once for as long as they are in the teleICU bunker, which is located inside the hospital.
Critical patients themselves have also benefited from the increased use of technology within the health care system, Fiona Wu, a nurse who works in the YNHH COVID ICU, said. The use of iPads and other video conferencing devices and platforms, although not really prevalent before the pandemic, currently allows many of COVID-19 ICU patients to stay connected with their loved ones outside the hospital.
“We did purchase a whole bunch of iPads, we do Zoom meetings, I often just set it up, kind of prop it on the table,” Wu said. “They’re honestly so grateful and so happy just to be able to see their loved ones, but if we can’t figure out Zoom, I just put them on speaker and I just leave the phone by the bedside. … They call like 24/7.”
Impact of technological equity on health equity
While Leslie Asanga SPH ’20 was studying at the Yale School of Public Health in early 2020, he was also working part time as a pharmacist. When the pandemic first hit, he noticed that the elderly, immunocompromised and members of communities of color were not consistently picking up their medication.
“When the pandemic started, especially in New Haven, the bus system was closed … and a lot of these people don’t have cars, who are the people who rely on bus systems, so it really disproportionately affected them,” Asanga said.
“A lot of [this technology] — especially in health, which is sad … is being built for profit … And when they are being built for profit, they are neglecting the people that really need it the most, to be honest like the seniors … [and] minorities that tend to have multiple disease states.”
—Leslie Asanga SPH ’20
In response, he founded Pills2Me, a tech startup that made pharmacy services available remotely through on-demand delivery. Part of Pills2Me’s mission involves bringing medication to people who need it but might have difficulty seeking it out in person. For people over the age of 65, their services cost nothing.
The financial and business-oriented motivations behind many health tech companies are concerning to Asanga. According to him, technology has the power to change the world, but if it is wielded selfishly it can end up creating many problems — especially for vulnerable communities.
“A lot of [this technology] — especially in health, which is sad … is being built for profit,” Asanga said. “And when they are being built for profit, they are neglecting the people that really need it the most, to be honest like the seniors … [and] minorities that tend to have multiple disease states.”
In the same way, however, Asanga noted that, if used with noble motives, technology can help break down barriers of access to health for many by eliminating difficulties that inadequate access of transportation, for example, could create.
“Telehealth allows us yet another pathway to interact and help patients, it really lowers that barrier to access,” Martinello said. “But of course, it’s not the end-all be-all.”
Access to technology is known to fall along socioeconomic lines, Martinello said. With that in mind, health care systems including YNHHS need to be mindful about facilitating remote access to their platforms for patients from all segments of society.
To that end, YNHHS has made it so its telehealth services can also be accessed through phone calls, eliminating the need for patients to have access to devices that can support video conferencing platforms such as Zoom in order to receive a consultation, Sussman explained.
“Using digital technology, we’ve been able to connect patients with care,” Sussman said. “In some of our federally qualified health centers, we’ve seen that the number of no-show appointments has gone down, because patients are now able to access care, and they don’t have to worry so much about arranging child care, or transportation, or taking time off of work.”
Early in the pandemic, telephone was an important modality for patients to access care, Sussman said. As video technology improved, telephones started to play a much smaller role, though there are still patients who are not able to access video visits.
Another means through which telehealth has allowed for more equitable care is through the facilitation of interpreter services. Throughout the pandemic, Sussman explained, the system has been able to evolve the services they offer. Currently, YNHHS patients can request simultaneous interpretation for over 100 different languages.
Part of increasing equity in technological access to health care, Sussman said, will also have to include initiatives to increase digital literacy among patient populations, but also in redesigning software and systems to make them more user-friendly.
Kyle Ballou, YNHHS vice president for community and government relations, told the News that the health system also had to adapt the ways in which it interfaces with local communities during the pandemic.
Though community health workers would normally visit neighborhoods on foot, much of their outreach efforts had to be moved to virtual platforms such as Zooms or online town halls, Ballou said. According to her, the system has also been able to count on the support of many local community leaders to understand the challenges people were experiencing throughout the pandemic, develop strategies to address them and, most recently, craft events and messaging to increase vaccine uptake.
“Internally we have town halls, where all of our employees can tune in once a week and hear what’s going on around the organization,” Ballou said. “We’re trying to use the technology to its best use for us to talk and interface with the community as well as have them talk and interface with us, but we’re still picking up the phone.”
Using telehealth to promote continuity of care
“Telehealth allows us yet another pathway to interact and help patients, it really lowers that barrier to access. But of course, it’s not the end-all be-all.”
—Richard Martinello, YNHHS Medical Director of Infection Prevention
YNHHS also had to contend with an overwhelming backlog of patients who had to forgo care earlier in the pandemic when lockdown measures had to be instituted. This, in addition to a fear of contracting COVID-19 in health care settings, deterred people from seeking care. Studies estimate that the long-term toll of chronic conditions which could otherwise have been more attentively treated, such as cancer and coronary heart disease for example, has increased throughout the pandemic.
To avoid a repeat of this situation in the future, YNHHS administrations have been advocating in the Connecticut General Assembly for legislation that could support the seamless long-term implementation of telehealth services.
“People delayed care, probably longer than they should have, and so what we’d like to do is prevent that from happening,” YNHHS CEO Marna Borgstrom said in a press conference on May 3. “We think that telehealth is one important way to do that.”
According to Borgstrom, the health system is pushing for the Connecticut General Assembly to adopt House Bill 6472 and Senate Bill 1022, which would both provide continuous reimbursement to providers of telehealth services that are either paid for commercially or subsidized through Medicaid. The hope, she said, is for this to give patients greater flexibility regarding where they would like to consult with their physicians — whether it is in person or through telehealth. If patients are supported to seek care in whatever manner is most accessible to them, Borgstrom said, this could prevent delayed care.
“We are continuing to advocate for the use of telehealth and telemedicine to keep people more comfortable in getting appropriate care where it may be safer and more comfortable for them,” Borgstrom said.
Innovation moving forward
After international emergencies such as this pandemic, Martinello explained, it is common for long-term changes to be put into practice. But even though considerable progress is often born of that phenomenon, so too is a loss in the energy that had been propelling that momentum.
“Something I really worry about, we’ve seen this in past pandemics, notably the 2009 pandemic, is that while there is a great deal of attention and resources put toward our current pandemic, there’s also a great deal of fatigue,” Martinello said. “Pandemic fatigue … [and] governmental and organizational fatigue.”
But the lessons learned along the way will help pave the way forward, he noted. Lattanza added that the spirit of collaboration and innovation will stay alive after the pandemic.
According to Martinello, the biggest challenge that health care as a whole faces as it leaps into this new technological age, transitioning from a pandemic-motivated health care model to a universally convenient one, is understanding how to best leverage the benefits of telehealth and understand its potential pitfalls.
The pandemic has proved, though, the boundless potential for innovation that exists within the health sector, Sussman said, as well as more specifically in telehealth. To him, it all boils down to providing the best possible care to patients, wherever they feel more comfortable.
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