Re-Think Health Podcast Series

Maria Palombini: Hello everyone, and welcome to the IEEE SA Rethink Health podcast series. I’m your host, Maria Palombini. I am the Director of Healthcare and Life Sciences Global Practice here at the IEEE SA.

This podcast puts industry stakeholders from around the globe on the spot to answer an important question, how can we rethink the approach to healthcare with the responsible use of new technologies and applications that can afford more security, protection, and sustainable, equitable access to quality care for all individuals?

We are delighted to bring you season five, the Rise in Demand for Telehealth, Equity, and Accessible Technologies and I’m delighted to say we’re presenting this in collaboration with the American Telemedicine Association, the ATA. The ATA is a nonprofit organization completely focused on advancing telehealth, committed to ensuring that everyone has access to safe, affordable, and appropriate care when and where they need it. Enabling the system to do more good for more people, and we all love that.

So you can learn more about the IEEE Rethink Health podcast series and tune into our four other seasons on ieeesa.io/healthpodcast. Or you can just scroll through the Rethink Health podcast channel.

So many of you out there might have heard this term are consumers of healthcare. The term was coined back in the 1930s, and in simple terms, the concept makes sense. We as patients are consumers of healthcare. are consumers of healthcare can mean different things to different people. However, the concept has been fueled by both a transformational mind shift in the idea of empowering patients to take control of their health data and the rise in demand for a retail shopping-like experience when it comes to healthcare services.

Many have argued that this concept of “consumers of healthcare” has been fueled by the growth of the use of telehealth services. No doubt we see a rise in the use in demand for telehealth, including the growth of RPMs (Remote Patient Monitoring services), RTM (Remote Therapeutic Monitoring devices). This concept of bringing hospitals to the home and more.

However, the rise does not reflect everyone. A late 2020 study published in the journal Population Health Management examines telehealth uses inequities during the pandemic. Essentially found what we already all know people in urban areas where doctors in care facilities are already in plentiful supply, were more likely to use telehealth solutions than those in rural areas.

And the same was true of people in wealthier versus less affluent locales and neighborhoods. So in season five, we are bringing technologists, researchers, clinicians, advocates, and a host of other stakeholders who will discuss this rise, demand, and need for telehealth, along with the growing concern to adjust the challenges prohibiting equitable access for especially the most vulnerable populations.

Since this is a special season as it is a collaboration with the ATA, our guests will be a selection of speakers from the 2023 annual conference, upcoming March 4th to the sixth, 2023 in San Antonio. And for those of you who are not familiar with the ATA, they always host a large annual conference every year.

So if you miss this year’s 2023 conference, You can definitely catch next year’s 2024. We’re going to hear from these experts on advancements of accessible technologies and infrastructure in progress and policy developments, as well as how much more is needed to have a more comprehensive approach to accessibility and equity in the telehealth system.

So before we get started, IEEE, nor the ATA, endorse or financially support any of the products or services mentioned by or affiliated with our guest experts in this season, five. Guests are invited to participate to offer opinions and perspectives representative of their own knowledge and experience.

So with that out of the way, now it’s my pleasure to welcome Dr. Joseph Kvedar, immediate past chair of the board of the ATA. He’s a professor at Harvard Medical School, and he’s also an editor of NPJ Digital Medicine. Dr. Kvedar, welcome to the Rethink Health Podcast.

Dr. Joseph Kvedar: Thanks so much for having me, Maria. I’m delighted to chat with you today.

Maria Palombini: I am so excited to get into this interview with you, so we’re gonna jump right into it. And you know, just because we’re audio only on podcasts, I like to humanize the experience for our audience, so, you have had a highly reputable career as a board-certified dermatologist, having completed your residency at Massachusetts General Hospital and are now currently a professor at Harvard Medical School. You are an early pioneer and continue to advocate for telehealth adoption. You’ve authored some interesting books, the Internet of Healthy Things and the New Mobile Age, How Technology Will Extend the Healthspan and Optimize the Lifespan.

You also do an interesting blog called C Health, which provides your insights and vision of connected health. So my question to you, as an early pioneer, can you share with us what drove your interest and passion for telehealth? What did you see in it at a time, let’s say 30 years ago, that others perhaps could not see?

Dr. Joseph Kvedar: Well, thanks for the question. It, it, it perhaps will sound a bit quaint, and you have to take yourself back, uh, listeners and, and then if you’re, If you’re a younger person, you have to imagine a world where the largest hard drive was 30 megabytes. The first digital cameras were one megapixel. It was a different world.

We didn’t think about moving things around. We were just starting to see something like the Netscape Navigator come in. So in that context, I was, uh, Assigned really as it turns out, by, by, uh, chance a project to look at this new technology called digital imaging. And would it be of diagnostic, uh, caliber in dermatology?

And it was really during a clinical trial in the early to mid-nineties of that tool that I had. Uh, it was like a light bulb went off one day, and I thought if you could separate. The mental, uh, intellectual activity of a provider from where the patient is. You could just open up all kinds of opportunities to change healthcare, access, quality, and efficiency, and I never really looked back.

Um, I had at the, in the beginning, I, I thought I was probably, this is the part that really answers your question. I, I thought I was among the last to have that, uh, Insight when, of course, I wasn’t among the last, maybe among the first, and so I thought, let’s get going and, and we sort of, I assembled a team and got some early funding from the hospital and started moving forward and, and sort of have pursued it since.

So the work’s not done, uh, as, as you point out, it’s, there’s still plenty to do, but we’ve, we’ve also come a long way in 30 years.

Maria Palombini: That’s, that’s, um, that’s awesome. And I think this really embodies the spirit when we say, how can we rethink the approach to health using these kinds of tools? But you started it a little bit earlier than the rest of us, so that’s what’s really exciting about it.

Okay, so, uh, I hear that you recently launched the ATA new podcast series, entitled Health Virtually Uncensored. So welcome to the world of podcasting. Um, maybe you could share with our audience, um, the mission of the series. Like what are the main points you would like to get out and hoping to use this medium, like to really emphasize or bring awareness to, uh, things of that nature?

Dr. Joseph Kvedar: Thanks again for that, uh, for that question. You know, audio, as, as you, you’ve talked about audio only already in this, in this interview, audio is such a special medium. I, there are lots of stats, and I don’t have all of them at my fingertips, but people will listen to a long-form podcast all the way through.

Uh, whereas if, you know you’re lucky on, on a, on a video, on Facebook or, or a. A tweet that you get, uh, 30 seconds of, of a viewer’s attention. So there’s something about the medium that’s very, very charming and, uh, intimate. Uh, you’re right next to someone’s ear. Um, and so with, with that in mind, I, I looked at our industry, and of course, it is ATA so we’re, we’re always, uh, bringing in people to talk about things that are on our minds at ata, whatever’s topical at the time, but there’s also.

The, the, the title is very deliberate and, and it’s, I think one of the things we’ve suffered from in, in our field over the years is people for whatever reason have tended to over, um, state a little bit their successes, whether that be through numbers of consults or revenue dollars or whatever their thing is.

So I wanted to bring in people that could really. And, and, essentially ask some hard questions too, like, what, what really needs to happen? Where are we really? What? And so we’ve done one episode, we have one coming out in, in a week or so. We’re gonna record a couple more at the annual conference. I have done podcasting before.

I, I love it as a tool and as a way to get the word out. So very excited to see it launch and, um, and move forward. And, the first one got a lot of, uh, attention. So we’re off to a good start.

Maria Palombini: That’s great. I agree. Way.

Dr. Joseph Kvedar: Uh, if I could, I just, um, the one thing that I realized after we launched, uh, I’m, I didn’t pick this up before, but if you wanna find it on Apple Podcast, your, your best to search either my last name, K V E D A R, or health.virtually.uncensored. It’s, it’s, uh, we probably have to change that, but it’s, if you just put in health or health, it won’t come up. So, and you can also find it on the ATA website. So we, we’d love for, have people, uh, rate, review, subscribe, et cetera. And, and thanks, for the plug.

Maria Palombini: Yes, absolutely. I think whenever we can get good information out to our listeners, I’m all, I’m all for it.

So, uh, definitely everybody, you podcast lovers, uh, please be sure to check it out. All right, so we’re gonna get to some good stuff. Why are we here? Right? What are we gonna talk about? It’s really important, so, yes. You know, uh, some have opined or argued that 90 to 95% of healthcare interactions by the year 2030 will be non-face-to-face.

This is pretty significant, but, uh, through our experience or your experience at the ATA in your research, you have written and advocated for making telehealth a permanent part of care delivery by creating a system of omnichannel care that includes both in-person and virtual care. So can you share with us how real this 90 to 95% number can be looking at some of the continued challenges, which I know you’ve written about as well, having with payers and disbursements, this confusion around policy and overall, not a very comprehensive rate of adoption from patients?

Dr. Joseph Kvedar: Yeah, that’s a great question. So, I guess I’d start by saying 90 to 95% seems quite aspirational to me. And, and I’ll quickly add that, I’m not sure why people aspire to numbers like that, right? Mm-hmm. The answer should be what is the right way for you as a patient to get your care in the moment? If it is the best way for you to get your care is through a chatbot.

Or through an urgent care facility If for a video visit you, you early referred earlier to remote patient monitoring, um, the point is you should have access to all those channels, and they should be, um, you should be using the one that best suits your need at the time. I, I don’t know why anyone would aspire to have 95% of our care delivered virtually.

Um, there, there are times when. Patients and or doctors really want to see you in person. There’s a reason why that’s special too. So it has to be balanced. Um, and I don’t know the right number. It’s interesting. I follow the Fair Telehealth tracker, um, which tracks the percentage of healthcare claims. Um, and it’s about 5% now of all claims or telehealth, just for quick comparison, before the pandemic about 0.2% were, were, so it’s, it’s been significant, it’s been consistent, uh, uh, for at least a year and a half.

Now that it’s about 5%, again, I don’t know if that’s right. That might be low, but 95% might be high. And either way, I think what we want to do is figure out. The best way to deliver care is, as we’ve said, telehealth is about access. It’s about efficiency, it’s about quality, and you as a patient have to be cared for in a high-quality way no matter what channel you use.

Maria Palombini: Absolutely. I think it’s really important. Uh, and I think it’s a good point. It’s like, what’s the best model that works for you, and what do you need to get? So totally, uh, an important point to get across. So, uh, getting, talking about access and obviously making sure people can have access to, to care. You know, we all know that there’s an inequity in the traditional healthcare system of care and delivery that has carried over naturally to the telehealth domain.

Many have argued that it’s. Simply because rural and marginalized populations don’t have adequate digital access infrastructure to use telehealth or digital health services. Would you agree or disagree that if the global community came together and just said, Hey, we’re gonna fix this issue of lack of digital access, would we really solve the problem, and would they, the patients utilize the telehealth system or maybe is the problem a bit larger and complex?

There is an issue of trust that seems to always fly under the radar, like trust, um, by marginalized populations in the healthcare system. I know this is a major area of interest to you in, in the work, in the research you have done. So maybe in your perspective, how can telehealth bring some trust into the healthcare system to mitigate this issue of inequity or fear of utilizing the technology and these services?

Dr. Joseph Kvedar: Well, well, Maria, let’s unpack that a little bit. There’s a lot in that and, and you sort of answered your own question in a way that, so, so the first, the first part is about, uh, extending broadband. Let’s pretend that we had a magic wand and we could put broadband in everywhere. Uh, you’re quite right that that is a step.

It’s necessary, but not sufficient. It’s not gonna solve the problem without it. It’s hard to solve the problem, but with it, the problem still may exist. Trust is part of it. Uh, digital literacy is part of it. Affordability is part of it. Um, and so the Ata I, I’m quite pleased with our, our CEO, Ann is a wonderful leader, and she pulled together, uh, over a year ago, a group on diversity, equity, and inclusion and telehealth to tackle this issue.

Because as much as people might say that telehealth and you, you cited a study earlier, um, Led to some inequities. We would argue that it could be a digital divide-crossing tool if employed in the right way because again, it extends access. And so many of those individuals we’re talking about could be urban, could be rural, doesn’t necessarily mean.

But having access, if you gave it to them in a way that was, uh, acceptable, uh, uh, would, would be I think an exciting thing. So that’s one thing we’re working on in terms of trust, you know, you’re quite right. I’ve, I’ve been thinking about this. I actually just published a blog on it, and I intend to talk about it at the annual meeting coming up in about a month that you referenced.

Uh, when I started out, I used to bristle at, at, uh, folks saying, um, Well, I guess this, this new technology that you’re talking about would be okay for a, for a patient who didn’t have access to a real doctor. Um, and I would get so annoyed at that because of course I was a believer from day one and an evangelist and trying to say, not only is it good for rural, it’s good for urban, it’s again, it’s another channel.

It’s not perfect, and it’s not the only channel, but it’s another channel. So, Um, that signaled to me early on, and I didn’t really articulate it this way, but it signaled to me that there was this sort of lack of trust that somehow, and it still exists, uh, there are many layers to it, but that somehow when you use a virtual channel to deliver a service like this, that, that there’s a, uh, an erosion of trust could be because.

You know, the old adage, no one knows you’re a dog on the internet, right? It could be because there’s an un sort of lack of familiarity on the internet. There’s a, there’s a randomness to it. Um, I often tell the story of a doctor who I was told by a friend, so I, I assume this is a true story since, but a doctor who took.

Uh, a video call with a patient with sitting on the beach with no shirt on, you know that individual, a man mm-hmm. Would never go to the office, I think with no shirt on. Right. Why, why do people feel like they can do that? So, I know I’ve been babbling a bit. There’s a lot to it. There’s a lot to uncover and trust, and again, it’s something that we’re gonna be focused on in 2023 at ATA.

So looking forward to unpacking and peeling back the onion and trying to fix it.

Maria Palombini: Hmm, absolutely. I think just overall anything trust in an internet or virtual environment, you just can’t help but have that complexity around it. Um, we see it in every, obviously, healthcare is naturally an area, but we see it in every other industry as well.

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Okay, so healthcare, consumerism. We as patients are consumers of healthcare, and there’s just been this theory of discussions, research papers more recently, and this idea of patients being empowered, uh, to take the driver’s seat of their health data and care, um, especially now that more and more they’re expected to pay out of pocket, um, for their services.

And a great deal of this is fueled by the convenience of the telehealth experience. We know where patients are, likening it to an online shopping experience. I mean, Giving your work, um, what is your perspective on this topic? Um, do you envision maybe a future with a full swing reversal where patients are completely in the driver’s seat, like complete medicine being, you know, patient-driven, um, and commanding that retail-like experience where they’re no longer waiting 30 minutes to see a doctor?

It’s like, I’m here, you service me now. Concepts, right? There’s like all this discussion, um, taking the full ownership of their healthcare, I mean, Where do you think telehealth kind of plays the, the best role in this mind shift?

Dr. Joseph Kvedar: Well, you know, this is another great, uh, thoughtful question I, I reminded of, of, uh, again, back, back in the day when I started, uh, doing this, uh, another trend that was, was happening early in, in my, in my career of, of, uh, telehealth was the trend of patients, um, looking things up on the internet.

And at the time, a lot of doctors kind of blanched at that. People would bring in printouts, To the doctor and the doctors would get very upset with him. Uh, we u at that time, we all sort of felt like, what, what’s between the patient and me? Is that big thick textbook on the shelf? My education, my, uh, use of a certain linguistic when I talk.

Uh, all of that sort of creates, um, a little bit of mystery around the role of being a doctor. Uh, and, and so some of that still exists. And I think it always will, like, you know, there are some professions, if you need an attorney, you need an attorney. I don’t, unless you’re trained as an attorney, it gets to a point where you, you need that expertise.

Unless you’re trained as a physician, at some point, you’re gonna need my judgment, and it’s citizen science that can only take us so far. But with that said, I think we are in an era, and increasingly where patients are in the driver’s seat. They’re voting with their feet on various types of health plans, whether it be virtual first or uh, et cetera, where they feel like if they need a certain service, they’re gonna get it.

And the other example I would give on this is all of these, uh, I would call ’em maybe carve-outs, but, but services like, uh, where you could get birth control filled on, on a, uh, website or you could get your, um, Uh, erectile dysfunction medicine on a website or there, there’s again, many of them, a lot in behavioral health.

And the idea behind those is simply pointing out that there’s a market need for, to make certain, what I call transactional services. You don’t need to get birth control filled. You, you don’t need a whole lot of relationship with a doctor. You just need to make sure it’s safe, and you get the prescription.

And, um, there are those snippets of care. If we as traditional healthcare providers were providing the service in a way that suited everyone, those companies wouldn’t be succeeding. So they’re meeting a market need, and I think we have to look at it that way and rethink how we deliver.

Our services. So again, long-winded answer, we’re, we’re in the middle of that journey. We’ll never get to the point where it’s totally like retail, I don’t think. Mm-hmm. But we are going towards a place where patients have much more control, and that’s a good thing.

Maria Palombini: Absolutely. And just for our audience, if you notice Dr. Kvedar said rethink. So it is an important part of our process in the healthcare system. There you go. Alright, so as you mentioned, and we talked about the annual ATA 2023 conference is upcoming in a couple of weeks, uh, from March 4th to the sixth, and obviously it’s gonna be in San Antonio. Um, and you also just mentioned a few moments ago that you’ll be presenting an important keynote on the value of building trust in the telehealth system.

But also the ATA is celebrating an important milestone. It’s 30th anniversary, which may shock some of our audience to know that telehealth has been around for more than 30 years. Um, so maybe you can share, um, your perspective on this important milestone. How much has changed? Obviously being an early pioneer and obviously seeing the evolution and really how much has been realized that was originally predicted versus what has really come to pass.

Dr. Joseph Kvedar: Yeah, again, love the question, and I’ll be, I, I promise you and your listeners that I won’t be, be too, sort of reminiscent of the good old days. Um, but one of the things I like to use as an analogy when this kind of question comes up is, and if you’ve seen the original film Blade Runner. Uh, there’s, there’s a lot of interest in that.

So that film was shot, I think in 1980 or so. Mm-hmm. And, and it allegedly took place in 2020. So, uh, at the time, that was 40 years in the future, we had things like flying cars that, that hasn’t come to be, but, but there was a scene where, uh, uh, the, the main character has a video conference, and what I find fascinating about that is, They got the video conference part, right?

But he went to a payphone to do it. Uh, there was no notion that you’d be carrying this thing around in your pocket that had a network, uh, video, uh, uh, storage, all of that rolled in, you know, photography, all that rolled into one tiny device. So those are some of the things that I think really have changed the world, the I, the iPhone and.

And the interface that Apple created, which of course was immediately adopted by Android, that sort of changed everything because it made it easy for people to interact with this tiny computer in their hand and do all these things. And we just don’t even think anymore about how important mobile is.

Search was a similar kind of advance, uh, just having browsers and being able to do work through browsers. Uh, having software in the cloud. I mean, there are so many examples, and I think in the last 10 years, wearables, uh, as well and, and the connectivity and the feedback that wearables give you. So that’s, that’s a little bit of a game-ish.

I’ll, I’ll give you that, but, but when I look back at the beginning and what’s funny about it was at the time, any, any point along the 30 years, what we, we thought we had. The right technology to do the job. And typically in healthcare, we’re always behind the technology. So, you know, in the beginning, we had these big, two, two companies were, were, uh, prominent VTEL and PictureTel, these big CRT displays with big, uh, codex underneath them, $70,000 a pop.

You had to run three ISDN lines. It was a nightmare. But we thought that was great and people did it. Uh, and again, 30 years fast forward and you’ve got it in the palm of your hand. You can connect anywhere wirelessly, and it’s different worlds. So all that said, it’s been remarkable, and yet as you and I have said, telehealth isn’t probably where we need it to be yet.

We still have a long ways to go to get it in that proper omnichannel world that we’ve talked about, and we look forward to, uh, those challenges and getting ’em right as time goes on.

Maria Palombini: Absolutely. I think it’s, uh, continuously evolving and emerging, uh, technology and domain. So, uh, I think we’re getting ready for this conference, right?

I’m gonna be there. I’m looking forward to it, but, uh, maybe from your side, you can share with our audience who may be coming, who may be thinking about coming. What are you, what are some of the technologies or issues or areas that you think are going to be covered at this series conference that maybe people, something new that maybe people should be like maybe keeping their eye on anything that maybe is caught your eye so far?

Well, I can’t necessarily speak to new technologies only because they show up on the exhibit floor usually, or, or in some of the research. Uh, we do have a very strong research track with posters and presentations, highly curated. Um, we have a lot going on on the exhibit floor in terms of. Uh, uh, supplier presentations and, and new things going on, trying to attract a lot of, uh, early-stage companies to show their wares as well.

And we have an innovators challenge, so there are a lot of ways, to get new stuff in. Um, but some of the themes, one of them is going to be, uh, this has been on our minds for two years, and it’s, or three, and it’s, uh, not going away, which is just extending. All of the regulatory environment is in the right direction to allow us to keep delivering this care.

Uh, we now have a window till the end of 2024 for most things, but because it’s an election year, we think we’re gonna really have only a year to try to get that, uh, extended further. So that will come up. Um, you know, this idea of omnichannel comes up, and that’s gonna be. Uh, a prominent one. We have an executive invited session for a whole day where people are gonna talk about, uh, you mentioned, we both mentioned, um, excuse me, equity, equity is a big focus of ATA So, so those are some of the themes. Again, it’s, uh, it’s a little bit like a com, uh, like a street, uh, uh, fair. There’s so much going on in a good way. So come learn. Meet people, um, in, in San Antonio is, is just a lovely place.

Maria Palombini: Absolutely, especially this time of year. Um, so, uh, you know, we’re coming through the close, and you know, Dr. Kvedar you have already given us so much insight. Um, perhaps you can share with us one final parting thought, um, and with our audience, share with them, you know, maybe something when it comes to the challenge, the issue. The need to gain wider adoption. You know, I think, um, these kinds of challenges take a village.

I don’t think no one person or one group can solve ’em. So, you know, what can we do as a technologist, a researcher, clinicians? Mm-hmm. Um, or any other, someone who’s committed to seeing the process, you know, become more trusted and ethical and equitable for all.

Dr. Joseph Kvedar: Sure. I thank you for the opportunity.

I, I mean, I, assume, that the IEEE audience is going to be people who are keen on innovative technologies, and my message to those folks usually is to simplify as much as possible, get, get as much feedback from end users in your, in your dev, um, development as possible. Unfortunately, when we have engineers devise.

Tools that other engineers, like, sometimes they don’t go as far in the marketplace as quickly as, as we might like, because people are, they’re, they’re, that’s, those people are really smart, and most of the folks they want to design for aren’t as smart as them. So just be really thoughtful about making things, uh, easy to use, intuitive, um, and exciting.

Uh, I think there’s a, you know, this technology nowadays, whether it be wearables or. Other, uh, apps, et cetera. The ones that are winning are ones that people just delight in using. And, uh, and I think we can make healthcare delightful in, in that way.

Maria Palombini: Absolutely. Um, so thank you, uh, Dr. Kvedar for joining me today. Um, this has been a really, really insightful conversation.

I wanna thank the ATA for collaborating with the IEEE Healthcare Life Science Practice to bring this special season five of Rethink Health, um, to you, our global audience. Um, you can learn more about Dr. Kvedar and his research, his blogs, they’re all available on, um, joekvedar.com and I’ll spell that for you all joekvedar.com. Just for all of you out there. Many of the concepts in our conversation today, um, are addressed in various activities throughout the IEEE Standards Association, healthcare, life science practice, and its, you know, standards and pre-standards, um, programs. The mission of the practice is to engage multidisciplinary stakeholders around the world, to have them openly collaborate, build consensus, and develop solutions in an open standardized means.

Um, we have activities such as wearables and medical IoT, interoperability, intelligence, and transforming telehealth paradigm industry connections programs, which are really addressing the many things around equity, accessibility, feasibility, privacy, security, interoperability by design, all these challenges we’re seeing, um, pervasive in our healthcare, uh, in our telehealth system.

If you wanna learn more about all of the activities, visit ieeesa.io/hls. So a special thanks to you, the audience. Uh, we invite you to share this podcast with your colleagues and networks to help get this information out, um, to those who want to make a difference and contribute to overall better healthcare.

We wanna thank you for joining and keeping doing the great work you are doing to improve our healthcare system. Be sure to tune in to our other episodes of season five, in which we’ll have some exciting speakers, um, from 2023 at the annual conference. Um, stay safe and well until next time.

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Maria Palombini
Hello everyone and welcome to the IEEE SA Rethink Health Podcast Series. I’m your host, Maria Palombini, Director of the IEEE SA Healthcare and Life Sciences Global Practice. This podcast takes industry stakeholders, technologists, researchers, clinicians, regulators, and more from around the globe to task. How can we rethink the approach to healthcare with the responsible use of new technologies and applications that can afford more security protection and sustainable equitable access to quality care for all individuals?

We are in season four of the podcast series. You can check out our previous seasons on ieeesa.io/healthpodcast.

As we all know the result of the recent pandemic, the term telehealth has become one of the most frequently used ones, and it does not appear to be going away soon. The reality is the way we see telehealth today will look very different tomorrow. It’s manifesting in many different forms. It’s more than what we commonly see as a doctor/patient exchange on an audio/video platform.

It continues to grow, especially with RPM devices, Remote Patient Monitoring devices. The telehealth experience has changed the patient’s expectations on healthcare services. They’re relating it more to a concierge level, online retail experience: convenient, appropriate, and personalized.

And then there’s this growing RPM space. There’s so many different forecasts when it comes to RPM. Anywhere from U.S. 150 billion dollars by 2028 to estimates that 40% of patients will utilize one or more of these types of devices at one given time. But here’s one thing for certain, regardless if we’re talking telehealth, mobilized health, RPMs, the future of delivering healthcare is not confined to a facility and it will need to be patient-centered.

So season four, of this podcast series, Telehealth’s Quantum Leap into Patient-centered Care, talks to the innovators. These are the winners of the IEEE SA Telehealth Virtual Pitch Competition, the industry leaders, clinicians, and other researchers who are at the forefront of driving innovations with solutions on accessibility, human factor design, flexibility, interoperability, security, inclusivity, and any other necessary ingredient to migrate telehealth care to a patient-centered care system.

So a short disclaimer before we begin, IEEE does not endorse or financially support any of the products or services discussed by our guests in this series.

It is my pleasure to welcome Sanna Gaspard, CEO of Rubitection, Inventor of the Rubitect Assessment System to our conversation.

Hi, Sanna, welcome to our podcast.

Sanna Gaspard
Thank you for the opportunity. Looking forward to talking to you today.

Maria Palombini
I’m excited to have Sanna here with us! Rubitection garnered the first place position in the entity category of the IEEE SA Rethink the RPM Machine Competition.

So Sanna, before we get to the core of your innovation, tell us a little bit about you. You’re CEO, you’re an inventor of this solution, what drives your passion in your work? How did you get here?

Sanna Gaspard
What really drives my passion in my work is being able to innovate to improve healthcare. I have a PhD in Biomedical Engineering with a specialization in Medical Device Development and Commercialization. I came to that after thinking about being a pre-med to become a doctor and realizing that wasn’t the best career for my personality and what I wanted to do. I decided I really wanted to still have an impact in healthcare, but maybe on developing the technology that doctors use. And so now I’m just passionate about getting the technology out there to help caregivers and patients.

Maria Palombini
I think it’s fascinating because I’ve interviewed physicians who are migrating over to IT and Technology Design because they felt like, well, this is really what I wanted to do.

So we often hear that starting a company in this space derives from some sort of personal experience. Somehow they may have been afflicted, a family member, or something they came across doing university research. Is there a personal story behind bringing this innovative RPM approach to wound care? What was the vision and impact you imagined that it could have for patients?

Sanna Gaspard
So the personal story was really driven more by my desire to want to improve healthcare as a career than personal experience with the condition. I came across a condition while I was in grad school. At the time I was looking for a project where I could develop technology to improve care, but I really wanted to focus on something that was a healthcare problem, that was very common, but being overlooked.

And so when I learned about bed sores and I went and researched it, I found that it was killing like 60,000 people every year, affecting 2 million people per year, but the assessment approach was really still something that was manual where technology could be used to improve that assessment to save lives.

And so that was really what drove me to do that, I wanted to make sure that I spent the time on my PhD doing something that I could translate out to improve care and really address a real healthcare problem.

Maria Palombini
Absolutely. So it’s interesting, we often hear you need thicker skin to survive in this world. And in this case, you just mentioned 60,000 people die from complications due to bedsores every year, people think, oh, it’s just a little condition, but it does take people’s lives. That’s one person every nine minutes, so it’s pretty significant and over 55% of nursing home residents die from bed sores within six weeks of onset of the wound.

We all may have elderly relatives living in nursing homes, this is something we all have to consider. So let’s get to the core of the interview of how this RPM innovation can start to really have an impact.

Can you share the types of research, maybe some modeling in the years that worked, that went into developing this product? What would you say in your research was the most interesting piece of information that came through in this R&D phase?

Sanna Gaspard
The most interesting piece of information I would say was twofold. One, how long the problem was outstanding. There’s comments back to Florence Nightingale and I think even possibly some references in Egyptian literature to these wounds and bed sores. But there was no real solution at the time. And that was partly being driven by legislation and policy partly because a lot of the costs for those wounds was being covered by the insurance companies and Medicare. But as they’re providing primary care and the patient develops a wound, they would still get additional payments for that care. So for me, that was a striking thing that was driving a lot of the lack of innovation in this space. There was a longstanding need.

The other thing that really caught my attention was the importance of correlating the technological platform to the clinical environment and how important that would be. So when I first learned about the issue, I went and researched all the different technical logical approaches you could use like ultrasound spectroscopy ,temperature and tried to match that against the user needs in that environment to see what would be the most appropriate. And I found that really was an interesting exercise in terms of like someone who’s interested in developing tech, you can’t just go and say, oh, I think this is a tech I want to use or the technological platform I want to use to solve this problem. You really have to cross check it around what the users need and how it would integrate into that environment around usability and ease of use. That was a lot of the early work I did that drove the direction of the technology in terms of development.

Maria Palombini
There are many different skin conditions from eczema to bed sores to wound care. How does the RAS system work to identify the abnormality? And at the same time, how can it indicate what exactly is the abnormality? Like it’s a diabetic ulcer, it’s a bed sore, it’s a wound, whatever it may be.

Sanna Gaspard
The Rubitect Assessment System, abbreviated RAS, is essentially a device that helps to assess the skin to identify chronic inflammation or conditions in a dermatology space or in the wound care and surgical space. So in a dermatology space, it could be used for things like rosacea, eczema, eventually, maybe things like skin cancer for early screening and in the wound care space, we’re looking at diabetic foot ulcers, pressure injuries and surgical wound monitoring.

It essentially includes a software system that you can monitor data on and a device that you place onto the skin to make measurements of the skin, to identify areas of inflammation. So you place a device on the skin. It makes a measurement predominantly using optics, and then you get an assessment following that measurement about low, medium, or high risk or gives you a diagnosis.

And you can then share with your primary care physician to get an updated care plan or to understand the next steps in the care plan. Our real goal with that system is to really support effective early assessment to prevent the progression of advanced wounds or to help patients in a dermatological space, either do early assessment to evaluate treatment effectiveness based on the prescriptive treatment that their doctors provided so that they can support care compliance and using the system, or get a new prescription if that product is not working. On the wound care side, it’s catching it early to prevent advanced wounds that can be deathly.

Maria Palombini
Very interesting. So we’re trying to get ahead of the game here.

Sanna Gaspard
We’re trying to get ahead of the game and empower people.

Maria Palombini
One of the key features that you presented in the competition is that the data collected is interoperable with medical health records, which for patients, that’s a great opportunity. How have you seen physicians and caregivers use the data collected about the patient to sort of alter their care, to make it better and how does the data collected actually integrate into their patient’s medical chart?

Sanna Gaspard
So right now, we’re still in R&D. So we haven’t fully launched the product, but when we launch it, we depend on having an EHR integration. From a remote patient care standpoint, the measurements they do at home to provide a risk assessment or to do care planning and management would be sent back to their primary care physician.

Where they would confirm the data, confirm the care plan, and then also be able to save that in the EHR. When using an acute care setting, it would just be an inherent part of the EHR as they’re using the system. The data’s then also stored in the EHR for later data analysis or reporting and documentation.

Maria Palombini
We mentioned nursing facilities and long assisted living facilities. So one of the population sets that this may benefit is naturally the aging population. However, when we think about the aging population, they’re not usually considered the most digital and or trusting of these types of technologies.

What has been your experience or in research, being able to reach this age demographic, to utilize the RAS system, to trust it, to want to use it? What are some of the lessons that you might have learned through this engagement?

Sanna Gaspard
I would say some of the lessons I’ve learned through this engagement oftentimes is that you have to go through a family member or you have to go through their adult child.

Oftentimes their adult child is the person providing care or the nurse is the person providing care. So the main part of targeting this population is going through their care provider or their primary care provider, or the person who’s managing that care. And then basically working with that person to either explain the importance of the problem or how the technology can really help support them in managing that care.

But oftentimes getting access directly to those potentially elderly patients can be difficult, because you really can’t necessarily go to them directly. You have to go find their care provider.

Maria Palombini
Trying to turn caregivers into advocates for the use of this technology in order to help this area of the population.

Sanna Gaspard
Yes, exactly. And finding those caregivers in either advocate groups or finding those consumer targets in a home setting can be difficult. You’d have to go through the primary physician or the primary care provider. Basically go that way.

Maria Palombini
When we think of the pool of patients, it’s more than just the aging, because we’re talking a wide swath of wound care issues, other issues, diabetics. How do you see your technology being patient-centered? And when we talk about patient-centered it could be a point of accessibility, inclusivity, feasibility, adaptability. Is there a population of patients that you can better serve with this technology that perhaps could not be reached or accessed or included before when it comes to RPM opportunities?

Sanna Gaspard
We’re working on a skin health assessment tool that has applications in dermatology, in wound care, and surgery. In all of those fields for patients who have chronic dermatological conditions like psoriasis or eczema and even skin cancer, oftentimes, they would have to come into the office to get an assessment, or they were sending pictures or using really crude technology to try to document their condition to eventually share that with the doctor when they went into the office. Also true for patients with wounds so that when the patient goes home, their family members and caregivers are told here’s the care plan to help prevent this person from getting a wound but then they only see the doctor once the wound develops. So that makes prevention and early detection really difficult.

So really in each of those market segments, we are providing an access to a level of care that wasn’t available before, unless you went into the doctor’s office. So now you can have in-home monitoring to monitor changes in the skin to catch things early, share that with your physician, get an updated care plan, then catch things at an earlier stage when they’re least costly and the easiest to treat.

Maria Palombini
That’s a fascinating point. Because as a caregiver, you call a doctor and how you articulate something is not going right in a medical way. So I think this is a fascinating area because that is one of the caregiver’s biggest concerns. Can I take care of this at home? Am I capable of doing this? How about if something goes wrong? You get all these questions, right?

Sanna Gaspard
Exactly. And then in talking to caregivers in the home setting, another thing that comes up is like, as you’re responsible for that care for your loved one, your parent, your grandmother, maybe even a disabled child or someone with a chronic health condition, you’re trying to do your best to manage the care and manage your life. And when they get something that’s preventable, like bed sore that can be really severe. There’s a lot of guilt and shame associated with that oftentimes because they feel responsible and we really want to just help empower caregivers to understand that without technology, it is really hard to do that early detection and then to empower them to feel like they have the tools to prevent some of the chronic complications of a bed sore so that they can feel confident in the care that they’re providing in managing that care.

Maria Palombini
Absolutely. That’s a great benefit for caregivers out there. For sure.

As a tech startup, would you think of any technical standards, policies, opportunities, or something in place that would’ve made the development of this product go faster, easier. And after going through this process, what areas have you identified would open the doors to innovation in the telehealth space? And in your opinion, what would be the best way to address it?

Sanna Gaspard
One is funding because you need funding to be able to develop the technology. And I think having technical organizations that can support technical founders in getting access to funding or providing funding as investors or grants would be already a great start.

And I think also from a medical standpoint, technical standards around EHR integration would also be really helpful in meeting that HIPAA requirement because there’s so many ways, it’s usually customizable to each person’s technology, but having really clear standards about how you have that healthcare integration with each EMR systems would go a long way. Because all of the EMRs are slightly different, how you communicate with them in their platforms. And so it makes tech development with EHR integration very cumbersome and expensive.

Maria Palombini
So it’s almost like a tech entrepreneur mentorship sort of way of helping tech engineers. One being able to understand how to source and get funding as needed as they’re developing the product. But also understanding what tech guidelines are out there that maybe no one knows about, because we tend to always uncover these things and even say, okay, they’re not existent, but maybe this is something else you can use.

So I agree. I think there could be some definite guidance from people in that role before, and probably can point you in a faster, easier way to get to the answers you’re looking for.

Sanna Gaspard
Yeah, I would agree with that.

Maria Palombini
You’ve given us some really interesting insights, especially when it comes to this whole area of therapeutic on the health side and the opportunity of supporting the caregiver for which we don’t see too often in a lot of RPM devices. What is something that you would like to share with our audience? It is a diverse group. We have technologists, we have people in the clinical field. We have researchers, regulators, policy people, whoever’s listening to this podcast. What would you like to share with them when it comes to really understanding developing technologies under the context of patient-centered care?

Sanna Gaspard
I think the most important thing is that it takes everybody. Technology can’t be created in a vacuum. As someone developing technology, I need access to healthcare providers. I need access to the caregivers and patients to understand what their needs are. In terms of the clinical providers, I need access to them to understand clinical integration and use cases and how to ensure that the device meets usability requirements and also clinical integration requirements. Policy makers usually end up driving things around pricing and large market drivers that affect adoption around reimbursement or medical policies for use or requirements for use in reporting that really end up driving clinical adoption. And also things around regulatory issues like the FDA. So it really takes everybody and there should be really more groups where that brings together a diverse group of stakeholders that technologists can access in one place. So like right now, if I wanna talk to a doctor, I have to go and find a doctor. Then I have to go and find the patient in a different location. And I have to go find the stakeholder from a policy standpoint in a different location. There’s not one place that you can go and get a holistic view of the problem to get the perspectives of each major stakeholder in one setting.

Maria Palombini
I can see that, but that’s also symptomatic unfortunately, of the healthcare system, right?

Sanna Gaspard
It doesn’t have to be fragmented. I mean, people have historical data of their images of their personal life and we can’t manage to get longitudinal data of our own health.

Maria Palombini
That’s a very good point. Sanna, thank you so much for joining me today and sharing all these exciting insights.

Sanna Gaspard
Thank you as well for the opportunity. I enjoyed talking to you, and if anybody wants to reach out, they can shout to me at [email protected].

Maria Palombini
Absolutely. If you guys wanna learn more about the Rubitection Assessment System and about Rubitection in general, you can visit rubitection.com. And you can learn all about Sanna as well and her advisory team and all the other information that’s on there.

Many of the concepts we talked about with Sanna today are addressed in various activities throughout the IEEE SA Healthcare & Life Science Practice. The mission of our practice is engaging multidisciplinary stakeholders and having them openly collaborate, build consensus, and develop solutions in an open, standardized means to support innovation that will enable privacy, security and equitable, sustainable access to quality care for all.

And these are activities such as WAMIII: Wearables and Medical IOT Interoperability Intelligence Incubator Program, and Transforming the Telehealth Paradigm Industry Connections Program. And there’s a whole host of others in Decentralized Clinical Trials, AI, Digital Therapeutics for Mental Healthcare. So if you’re interested in learning how you can get involved or think about instantiating an activity, you can visit our practice website at ieeesa.io/hls.

If you enjoyed this podcast, we ask you to share it with your peers, colleagues on your networks. This is the only way we can get these important discussions out into the domain is by helping us to get the word out. Be sure to use #IEEEHLS or tag us on Twitter @IEEESA or on LinkedIn, IEEE Standards Association.

I wanna do a special thank you to you, the audience for listening in. Continue to stay safe and well until next time.

Maria Palombini
Hello everyone and welcome to the IEEE SA Re-think Health Podcast Series. I’m your host, Maria Palombini, Director of the Healthcare and Life Sciences Global Practice here at the IEEE Standards Association. This podcast series takes industry stakeholders, the technologists, the researchers, clinicians, regulators, and more from around the globe to task, we ask them how can we rethink the approach to healthcare with responsible use of new technologies and applications that can afford more security, protection, and sustainable, equitable access to quality care for all individuals?

We are currently in season four, but you can check out our previous seasons on ieeesa.io/healthpodcast. So we all know as a result of the recent pandemic, the term “telehealth” is frequently used and it does not appear to be going away soon. The reality is that the way we see telehealth today will look very different tomorrow.

And it’s manifesting in many different forms. It’s more than what we commonly see or think as the doctor/patient exchange on some sort of audio or video platform. We look at innovations in RPM, remote patient monitoring. We look at how telehealth experience has changed even the patient’s expectation on healthcare services relating more to a concierge level, online retail experience, convenient, appropriate, and personalized.

And with this growing RPM space, there’s so many different forecasts when it comes to it anywhere from U.S. 150 billion by 2028 to an estimate of 40% of patients may be utilizing one or two of these devices at one time. But one thing is for certain, regardless if we are talking telehealth, mobilized health, or RPMs, the future of delivering healthcare is not confined to a facility. It will need to be patient-centered.

So season four of this podcast series, Telehealth’s Quantum Leap into Patient-centered Care, talks to the innovators, which are the winners of the IEEE SA Telehealth Virtual Pitch Competition, the industry leaders, the clinicians, and other researchers who are at the forefront of driving innovation with solutions on accessibility, human factor design, flexibility, security, inclusivity, and any other necessary ingredients to migrate telehealth care to a patient-centered care system.

A short disclaimer before we begin, IEEE does not endorse for financial support any of the products or services mentioned by or affiliated with our guest experts in this series. And now, it’s my pleasure to welcome Dr. Shayan Vayas, Senior Vice President and Medical Director of Clinical Operations at Teladoc Health.

Shayan was also a judge and advisor on the IEEE SA Rethink the Machine: Transforming RPM into a Patient-centered Care System Virtual Pitch Competition. And he’s also a participant in our Transforming the Telehealth Paradigm Industry Connections Program. Welcome Shayan.

Shayan Vyas
Thank you very much, Maria. It’s a pleasure to be here with you and IEEE listeners.

Maria Palombini
Before we get started to the core of the awesome work that’s going on at Teladoc, Shayan, you started with a successful career as a physician and you transitioned to virtual care and IT design. What was the catalyst for this change?

Shayan Vyas
Being a critical care physician, I’m at the frontline with the team, treating the sickest patients in the hospital. It’s the most vulnerable time for patients and families. This experience taught me a lot about obviously medicine and really the patient experience, but also mortality. As we think about how technology transsects patients, physicians, and clinicians, it significantly helps them, but it also can overburden them.

Furthermore, clinical care or even just bedside medicine is a model of one to one. I deliver care, clinician or nurse delivers care one to one and that’s not scalable. Even during my early training, when I was doing missionary trips as a young clinician, I wasn’t well experienced and I was still learning the art of medicine.

I wasn’t typically seeing bread and butter illnesses. And at this time, I really started to begin valuing and using technology. Phones started having the capabilities of doing video visits pretty easily and it’s become part of our everyday life.

That moment when I used the device to be able to call my mentors and my coaches back home during these trips, I realized this could be a catalyst. This could be a transition of how one to one can be one to many; how others can be impacted if I’m in another world, another country delivering care, and I’m able to connect to specialists and mentors back home, how can this affect the patient?

Technology can redefine the world we live in. We’ve seen that with innovators like Steve Jobs, Bezos, think about that with healthcare. There’s gotta be a way where we can take IT design and virtual care and just redesign the world that we live in, in healthcare.

Maria Palombini
Absolutely. I remember we were having a meeting one day in our telehealth group, and you just said something in passing, but it caught my attention. And I remember you vividly saying that tides have turned. No longer is the patient’s health experience like beholden to the times when you go to a doctor’s office and you have to sit there for hours, waiting for them to let you in. Like a patient’s demands are changing. And they want that concierge level experience as they get with retail. So how do you see telehealth overall, trying to meet that changing need?

Shayan Vyas
Patients are patients, but in this context, let’s say the word consumers, right?

So patients/consumers, they’re bringing their everyday expectations from other industries into healthcare. They’re intersecting their experience when they shop online or they stream a movie or even buy an airline ticket into healthcare and other industries. That experience that they enjoy and have the flexibility of doing in entertainment or shopping or whatnot, they’re starting to expect that in everything that they do. When’s the last time the listener actually went to the airport to buy a ticket? When’s the last time the listeners actually went to a store and rented a movie? That haul has changed. Even more, if you’re outside of a very large city, like New York, I’m in now, when’s the last time you actually flagged down a cab or you drove to a restaurant to carry out? Those things, they’ve revolutionized the world we live in. They can be done on an app or a browser. And that same consumer experience is what folks are craving when it comes to healthcare.

Consumers/patients, they don’t wanna wait in waiting rooms anymore. They don’t wanna wait six weeks for their PCP to send them to a specialist. Telehealth is just the beginning of this transformation. It allows that one to many that I described earlier, but more importantly, it’s starting to meet the bend of what consumers are demanding. I think this transformation of healthcare is just getting started. The in person aspects of medical care or going to the doctor will be held for the very few life threatening procedural needs.

I really believe that the tide has changed in that healthcare historically was built around the doctor, my waiting room, my parking lot. You’re gonna go on my terms, it’s changed to the patients. Patients now can schedule visits, they can go and look up what medical school I went to and what my press community score is. They can now shop around and that power is obviously well deserved. Consumers should know where they’re walking into. They have the right to choose what movie they wanna see, they can see the reviews and what others have said about it. The same thing should be in healthcare.

The tides have changed.

Maria Palombini
Absolutely. I think we get caught up in everything and sometimes we don’t realize that because innovations are coming out so fast, we lose sight of some of these things.

So Teladoc is one of the top 10 telemedicine companies founded in 2002. There’s rankings all over on the internet, but it’s always in the top 10 and that’s 20 years ago. The world really wasn’t talking about telehealth, nowhere near at the level we do it today and it’s actually only the publicly listed telemedicine company. So obviously the pandemic catapulted, the use of telehealth out of necessity. However, Teladoc was already on its way.

Do you find that Teladoc’s success is founded on its principle, that it’s a patient-centered platform?

Shayan Vyas
Absolutely. 20 years ago when Teladoc started, our physicians were actually breaking the law. We were taken to court and we ended up counter suing my home state, the board of medicine there.

And we changed the way society and law looked at a physician and a patient relationship. We did that because it was all about the patient-center. We wanted patients to have access to healthcare 24/7 without having to leave their home. In my mind, that ruling and the fundamentals of our company changed the balance of the physician “owning” the individual patient.

And it allowed now the patient to really understand and own their journey when it comes to healthcare, their choices, their flexibility. This is a transformation in not only just the law, but medical economics, and the fundamentals for consumers, obviously that propelled us to be the first publicly traded company and really the largest virtual company in the world.

It’s all about the patient. We have to deliver high level quality care. That’s an expectation that is a basic need in healthcare. Patients deserve to get the highest quality of care, but changing the principle around and delivering a platform that the patient can control was fundamental.

Maria Palombini
I think often we see innovations coming out and it’s all about, oh, the next best shiny thing. And it can do this and that, but we lose sight that we’re still serving the critical need of the patient. And I think this is really interesting. So for all you out there, Telehealth Doc, this was just released publicly. They signed a partnership with Northwell Health. And for those of you outside the New York Metro area, Northwell Health represents, one of, I think, New York’s largest healthcare provider. And the goal is to better provide access to virtual care across its enterprise. So we definitely focused on the patient, but one of the things, when we think of telehealth services, we think it’s easy, right. You just plug into a platform, turn on the mobile device and let’s connect and, obviously have the doctor/patient experience.

What are the considerations for the workflow from a physician’s perspective that must be changed to accommodate this transition to virtual care?

Shayan Vyas
A comment on Northwell, they have one of the greatest CEOs in the healthcare world ever. Very great organization. Over 18,000 physicians. They’ve been practicing telehealth for a long time.

When it comes to accommodations to transition to virtual care, there are multiple consumers that are using the platform. There’s the health system. So the administrators from the health system need to have data. There are physicians and now nurses and all kinds of clinicians are working. So we’ll use the term clinicians and then there’s the patient. There’s the IT team.

And so all of these consumers need to be thought of. So when we first started out, as mentioned previously, we built a platform really around the patient, but now there’s multiple end users that need to be thought of. You gotta think about those that we just mentioned. And in terms of thinking about how to transition everything to virtual care, the bar to virtual video visits is very low.

There are many ways to do a virtual visit now. You can do it essentially for free now with any app, to connect with grandmother or to connect with colleagues around the world. That bar is now very low. Everyone has a video platform. The bar to scalability is very hard. The bar to interoperability within multiple EMRs.

I think Northwell has 22 hospitals, 830 facilities, the integration in and out of the firewalls and in all the data systems that they’re using, that’s the hard part. And then when you multiply it, we have over 600 health systems around the world that we work with.

That is really hard in terms of just the individual physician’s perspective to replicate the in person experience or has to make it much easier.

Physicians are wasting a lot of time today with stuff that is not really adding value to the patient, the care they’re delivering, or even the ROI that the health system is investing in. And so when we think about adding video conferencing, it’s not just that. You have got to amplify the ability for folks to be able to practice at the highest level of their license.

Maria Palombini
It’s very interesting that you mentioned that because I was talking with Dr. Keith Thompson, who’s also part of the Telehealth Program and he said almost the exact same thing from a clinician perspective. As doctors we’re getting in all this administrative action outside of actual care action, helping the patient because of all these changes in workflows. And he was saying that this is where it’s really important to understand what the doctor needs to focus on and what the patient needs to focus on. And then let the experts handle all that other stuff.

Shayan Vyas
Here’s the reality, right? As an intensivist, I have a different perspective than an ambulatory physician, but even as an intensivist, I spend maybe 10% of my time at the bedside. The other 90% is I’m a data clerk. I’m entering data into an accounting ledger. It’s not making patient care easier. It’s not making the care safer.

It’s really a billing machine. And when you talk to my ambulatory colleagues, they’re doing the same thing, right? They’re spending minutes. I think that the average family practice doctor spends eight minutes with a patient. And they spend 30 minutes just charting and documenting and clicking here and there. As a consumer, I would rather a clinician spend 30 minutes with me and then the eight minutes doing the charting that adds no value to the system, but is where all the money and the transaction occurs.

Maria Palombini
I’m sure patients would agree with you 100% on that point.

So as we move towards greater adoption or use of virtual care, more acceptance, how do hospitals best negotiate the balance of patients expectations for home care versus hospital facility care? They are significantly different, but we still have patients’ expectations when they’re not doing well. So how does that balance work out?

Shayan Vyas
Maria, this is a great question. So let’s take a step back. The origin of modern day telehealth started really with employers and health insurances. They wanted to figure out a financial way to lower the delivery of care. The emergency room versus a telehealth visit is significantly cheaper for everybody. Significantly easier if you can get your symptoms and your illness resolved that way. That’s really where it started. It was really around the payers. Regarding hospitals, they get paid for beds and heads. It’s a very common term. We’re in a fee for service world. And the best way to get paid is when you have a head inside a bed.

When you look at health systems like Northwell Health, Kaiser Permanente, Intermountain, they have moved out of this fee for service world where they no longer are getting paid based on every procedure they do. The fee for service industry itself has plagued healthcare. You go to a surgeon, they’re gonna operate on you because they get paid that way.

That’s the way the model was. There was no value incentive for a surgeon not to operate on you. And so as we move from this fee for service world and to this value based world, that’s where we start to move the needle. The financial incentives now to actually do what’s in the patient’s best interest, try to deliver on this expectation that consumers or patients have in home care versus hospital care.

That’s where we start to see the needle move as more and more health systems start to develop MA plans and they start to take financial risk. They’re starting to think about how they can move away from bricks and mortar care to virtual care. That’s easier for everybody, it’s cheaper for everybody. And that’s how it’s gonna happen.

I think health systems are gonna have a hard time to be honest, trying to deliver full based virtual care when they’re fee for service. It’s not the same. It’s dollars to pennies when you meet in person versus you see me in virtual, in that fee for service world, but in that value based world, as long as I deliver the care, no matter if it’d be virtual or in person, delivering that care is what it’s at.

Patients are expecting that virtual visit when they go to the doctor or they have a surgery and they wanna do that visit. It’s a standard that a patient expects. But again, there’s a balance of getting paid and when health systems and physicians are getting paid more in person than virtual visits, then that’s a challenge.

It’s hard to move the financial needle that way. But as health systems and CMS are starting to push really for this value based care will really exponentially propel telehealth and virtual care.

Maria Palombini
I think that’s a really important transition that I think the whole industry needs to better evaluate and keep an eye on. I often say, and I talk about this with many different volunteers here at IEEE SA about the future of telehealth looking very different than it does today. And as a physician, why is it important to embrace the migration towards virtual care? The idea of bringing healthcare outside of the facility to the home and can it really improve patient outcomes? Can it actually better serve patients across the board?

Shayan Vyas
Before virtual care or even telehealth or remote patient monitoring, the standard for any of us was to go into the doctor, the bricks and mortar doctor. What did we learn from that? We learned that those that had access got better care. The proof is here. Everyone knows about DNA and genetics and hereditary diseases. Today 60% of health outcomes are determined solely by one thing. Do you know what that one thing is? Zip code.

Maria Palombini
Interesting.

Shayan Vyas
Not your DNA, not how long your parents lived, not the cancers that are in your family, but zip code is the primary determiner of your health outcome.

That’s fundamentally flawed. For those that live in a poor area, rural area, those determinants, what we call social determinants of health, access to fresh groceries, clean food, all of those things, high education, good paying jobs. Those are all social determinants of health, but when it comes down to access and one’s health, it was zip code.

And so as we think about this migration of virtual care, no matter where you live in this country, no matter where you live in this world, you can get access to Mayo Clinic. You can get access to. Kaiser to Northwell to all of these health systems. And that’s changed the game when it comes to access.

As we think about this embrace migration towards virtual care, I think that patients are gonna get better outcomes. That’s just the start of it. So there’s factors out there like the digital divide, not every American has access to high broadband, but those are being addressed. When we think about 60% of one’s health is determined by just your zip code.

We can change all that with virtual care.

Maria Palombini
Wow. Just the zip code. It’s so astonishing to think about. And I think this leads to my next question on health equity. Especially as there are marginalized populations without access to healthcare for a whole myriad set of reasons, but telehealth technically should reach those who are the hardest to reach. So in your view, how can telehealth equitably reach the patients who are currently not included in the healthcare system? What do you see as some of the challenges that need to be addressed so that telehealth could be a viable platform to close this healthcare gap?

Shayan Vyas
I think this is the golden question that a lot of CEOs, health systems, and those in the ecosystem are trying to address. We mentioned one of those barriers is zip code, but also the digital divide. Almost two out of 10 Americans don’t have access to broadband. Telehealth equity needs to address that.

It’s one of the main reasons that we merged with Livongo almost two years ago. Livongo was the first publicly traded chronic disease management company. What made them very successful and continues to help us grow is that all of the devices within that are sent to the patient doesn’t matter if they have access to broadband or not.

Why? Because they’re cellularly enabled. There’s cellular chips in the device, right? So glucose is checked for diabetics. The glucometer is the device that actually checks the glucose. Those devices have cellular chips in them. So we are automatically connecting these patients no matter where they are cellularly.

As we think about those that don’t have access. You gotta design it. We’re talking to the future entrepreneurs, engineers of the world. You have got to think of the basic connecting blocks when it comes to patient care. And so that was an MVP. Livongo started to make sure that the devices were all suddenly connected.

When you think about the scale of what we do at Livongo, we are now able to predict what folks’ glucoses will be, or predict mental illness for patients. And so, that’s the full spectrum that needs to really be addressed when you think about a viable platform that can help close the healthcare gaps.

Maria Palombini
I think that’s really interesting and I think you started the segue to my final question. You’ve given us so many great insights and talking to you is always an educational experience.

Any final thoughts, Shayan, about what you would like to share with our audience as it comes to really developing virtual care technologies under this context of patient-centered care; maybe it’s a call to action or a call to think about innovation in a different way.

Shayan Vyas
First off, Maria, thank you. I appreciate the invitation. I hope so far that it’s been insightful for your listeners.

Here’s my call to action or innovation: spending in the United States’s Healthcare System doubles every 13 years. The healthcare industry today is over 3 trillion (U.S.) dollars. If we continue, we’re gonna destroy the economy. There will be no social security, no retirement, the investments that we’re trying to make in our infrastructure, in our children’s lives, that will all be robbed to pay for healthcare. And so we have got to jump on this. I’ve never been more excited about healthcare and innovation. I’m excited. I believe in Moore’s Law, that technology dramatically increases in power and decreases in cost and that’s what gives me hope.

As you and I continue to age and when we get sick one day, we would love that technology to be “Uber” easy, right? Travis Kalanick with Uber, Elon Musk, Jeff Bezos, and Steve jobs- they were able to transform the world we live in into just a new experience that 10 years ago, we wouldn’t have even experienced.

I remember my mom would tell me, don’t get into somebody’s house that you don’t know. We do that with Airbnb. My mom also told us not to get into a stranger’s car. Now we’re calling strangers to pick us up. And so if you think about how those transformative leaders really recreated the world we live in, I’d love for your listeners to stay curious.

Think about equity when it comes to all people and don’t accept the status quo. The way we do something today is not okay. Think about how you can transform the world. If you stay curious and you have that open mindset that you want to help everybody, not just the financially well off, and you really challenge what we do, why we do this today, don’t accept those things.

So I hope that’s motivation and I’m looking forward to watching IEEE help a lot of startups and entrepreneurs. And I appreciate the opportunity. Thank you, Maria.

Maria Palombini
Thanks, Shayan, this has been really great. It’s really interesting you mentioned aging. We just started an activity for telehealth around robotics to support the aging, healthy, and assisted living for the exact same reason. I think we are expecting our aging population to outpace our younger generations, for sure.

Again, special thanks to you, Shayan, for joining me today, it’s been an absolute insightful experience.

Shayan Vyas
Appreciate it. Thank you.

Maria Palombini
And for all of you out there, if you wanna learn more about Teladoc Health, you can visit teladoc.com

Many of the conversation concepts we had here today with Shayan are addressed in various activities throughout the Healthcare Life Science Practice. The mission of the practice is engaging multidisciplinary stakeholders and have them openly collaborate, build consensus, and develop solutions in an open standardized means to support these goals around innovation that will enable privacy, security, and equitable, sustainable access to quality care for all.

Programs such as Transforming the Telehealth Paradigm, WAMIII, which is Wearables and Medical IOT, Interoperability, and Intelligence, and a whole host of other things on Decentralized Clinical Trials and Digital Therapeutics for Mental Healthcare.

If you wanna learn more about these projects and all these different activities, you can visit our practice website at ieeesa.io/hls. If you enjoy this podcast, we ask you to share it with your peers, colleagues in your networks. This is really the way we get these important discussions out into the domain is by you helping us to get the word out. You can use #IEEEH LS or tag us on Twitter @IEEESA or on LinkedIn @IEEE Standards Association when sharing this podcast.

I wanna do a special thanks to you, the audience, for listening and continue to stay safe and well until next time.

Maria Palombini
Welcome everyone. This is the IEEE SA Re-think Health Podcast Series. I’m your host, Maria Palombini, Director of Healthcare and Life Sciences Global Practice here at the IEEE SA. This podcast takes industry stakeholders, the technologists, researchers, clinicians, regulators, and more from around the globe to task.

How can we rethink the approach to healthcare with the responsible use of new technology and applications that can afford more security protection and sustainable equitable access to quality care for all individuals? You can check out our previous seasons of the podcast series at ieeesa.io/healthpodcast.

So as a result of the recent pandemic, the term telehealth has become a frequently used one and it does not appear to be going away soon. The reality is, the way we see telehealth today will look very different tomorrow. It’s manifesting in many different forms. It’s more than what we commonly see as the doctor/patient exchange on an audio/video platform. It can be so much more involved with innovations in RPM (Remote Patient Monitoring), mobile health, hospital at home, and many different areas. The telehealth experience has changed the patient’s expectations on healthcare services. They’re relating it more to a concierge level, online retail experience: convenient, appropriate, and personalized.

And there’s the growing RPM space. So many different forecasts when it comes to RPM, anywhere from U.S. 150 billion by 2028 to estimates of 40% of patients utilizing one or two of these devices at one time. But one thing is for certain, regardless if we’re talking telehealth, mobilized health, RPMs, the future of delivering healthcare is not confined to a facility and will need to be patient-centered.

Season four of this podcast series, “Telehealth’s Quantum Leap Into Patient-Centered Care,” talks to the innovators, winners of our IEEE SA Telehealth Virtual Pitch Competition, the industry leaders, clinicians, and other researchers who are at the forefront of driving innovation with solutions on accessibility, human factor design, interoperability, security, inclusivity, and the other necessary ingredients to migrate healthcare to a patient-centered care system.

So just a short disclaimer, before we begin, IEEE does not endorse, advocate, or financially support any programs, services, technologies mentioned, or affiliated with any of the experts who have appeared in this series. And with that out of the way, it is my pleasure to welcome Ronald Pulivarti, NCCoE (for those out there, National Cybersecurity Center of Excellence), Healthcare Program Manager and Nakia Grayson, NCCoE IT Security Specialist. The NCCoE is part of the National Institute of Standards and Technology, NIST. Welcome, Ron and Nakia!

Nakia Grayson
Thank you to IEEE for inviting us to do the podcast interview. And thank you, Maria, for hosting the interview. We are so excited to be here today!

Ronald Pulivarti
I’ll echo that. Thanks a lot for having us and to the IEEE community. We appreciate the opportunity to do this podcast with you, and hopefully we’ll be able to engage deeper and we can get some great learning from our conversation.

Maria Palombini
Absolutely. I think for our global audience out there, this is gonna be a great experience. Before we get to the core, the technology, what’s going on. I like to humanize the experience for our listeners, right. We’re all in a virtual world. So Nakia, you started out in a different role while at NIST and then transitioned to an IT Security Manager.

What inspired that change? What do you love about the work you are doing now?

Nakia Grayson
Before we begin, Ronald, I would like to just say that opinions we are going to share in this podcast are our own and not the opinions or positions of NCCOE and/or NIST. So to answer your question, yes, that’s correct. I started off in a different role at NIST and actually in an administrative role and later transitioned into IT Cyber Security role in 2018.

For my undergraduate studies in college, I majored in criminal justice. When I graduated, I really wanted to bridge my education and knowledge of the legal system with a career in technology, policy, and privacy, because since I’ve, you know, found all of those areas, I was already fond of those as a teenager. While working in a lead administrator role at NIST, I went to graduate school for Information Technology and while in school I became really interested in data protection and cyber security risk management and how both of these play a very important role in protecting and safeguarding the nature of critical infrastructure and privacy and sensitive data.

I really love working on this. NIST gives me the opportunity to work alongside world class talent and industry experts to tackle and solve the most complex problems in cybersecurity and privacy.

Maria Palombini
Excellent. Well, Nakia. We have a lot in common because I also did my undergraduate in criminal justice, but again, I didn’t go that path either. But an unbelievable opportunity to be working at the forefront on cybersecurity issues.

So, Ron, how about you? I understand that you’ve had an exciting professional background working in organizations, such as Health and Human Services ,the HHS. What have been some of the most exciting areas of your work? What would you say are some of the major compliments you have seen during your tenure?

Ronald Pulivarti
It’s quite interesting. I’m a technology nut, so one of the things that I’ve always actually noticed when I started at HHS is I was the guy picking up the support phone. So from understanding the nuts and bolts to actually managing these ecosystems has been such a great opportunity. I’ve been able to launch myself throughout different agencies within the HHS space. I was able to contribute and strengthen the technology foundation so that we could grow. And one of the big things that I felt like I was able to provide in this space was my technology experience. I see something and I think five years to 10 years ahead on where we should actually be. And I think one of the things or opportunities that I enjoy doing was taking a look at the current snapshot on where things are, and actually contributing and making a significant impact within the government space so that we can advance and we can grow and strengthen the government technology, workspace, and ecosystem.

And I enjoy it each and every day.

Maria Palombini
That’s awesome. We all know that we have to love what we do otherwise it really will feel like a job. And then that is not the point.

All right guys. For our audience, you got a little insight to our background and to the things that really motivate our guests today.

So let’s get to the core. Nakia, we hear about all kinds of risk in the remote patient monitoring ecosystem. What are some of the major risks you are seeing that can no longer go unaddressed? In simple terms, what exactly are we up against?

Nakia Grayson
Some of the major risks that we’re seeing in the RPM ecosystem, speaking from an organizational standpoint that can no longer go unaddressed, is when HDOs deploy RPM solutions.

These solutions are architecture that includes several components across the HDO, the telehealth platform providers, and the patient’s home. So each of these environments is managed by different groups of people and often with different sets of resources and technical capabilities.

So risk can cut across the architecture and the different methods by which one may mitigate those risks. And it can vary based on the complexity of these. So while HDOs do not have the ability to manage and deploy privacy and cyber security controls, they do oftentimes retain the responsibility to ensure that the appropriate controls and risk mitigation are applied.

So in simple terms, a lot of data is being transmitted back and forth across various platforms which can lead to access points to cyber criminals . So we need to ensure that we have the appropriate controls in place. The safeguard systems look deeper in the current infrastructure as technology advances, ensuring that we also have education training for our patients.

Maria Palombini
Yes. I think that’s a very important point, Nakia, because we all think that it can just be a simple apply, a patch and let’s move on. We really need to talk about the whole scope of what it takes in security. And that includes educating patients, because a lot of them might be completely oblivious to what’s going on.

So Ron, we’re seeing growing trends of non-clinical, let’s call ’em consumer-issued health IOT devices, being utilized by patients. They share with their health providers. With this new integration, what kind of security and privacy risks are to be considered?

What are some possible solutions? Do we rely on the healthcare delivery organization, the device maker? Who needs to step up and start creating some solutions here for all this data in these devices.

Ronald Pulivarti
Very good question, Maria. One of the things that we all need to really consider and think about is that as these devices are evolving, they’re constantly listening to us, right?

So understanding exactly the use of it and what we’re using it for and applying that privacy and security standard on how you wanna communicate outward. So understanding your surroundings is a critical aspect of that. And all of the groups need to be involved from the technology provider, from the HDO, even from the consumer.

Understanding the layout as we do every day rely on our technology IOT devices to turn on lights, we rely on it to turn on and adjust the thermostat. These are constantly pinging in our whole household. One of the most important pieces for our project, our remote patient monitoring project in our appendix E in our practice guide, we actually talk about the benefits of these IOT devices.

We provide the device capability mapping, the device capabilities that support these functional evaluations. But one of the big things that we really need to factor in is what means of communication are we using this device for and what safeguards can we put in our own house with communicating, whether it’s medical information, personal information, when you’re talking to your bank. You have to utilize that space to ensure that if these devices are constantly listening to you, where is the safest part in your house, that safe house? And you could actually have these communications without exploiting any information that you have.

As Nakia pointed out, there are bad actors every day. We’re constantly fighting them. So using those steps, I think in place to understand that there’s a constant chatter that’s happening in the background. Where is that safe place in your environment where you could actually utilize these devices to ensure that you’re safe and you’re properly communicating things without necessarily having someone intercept something in some form or fashion?

Maria Palombini
And that’s absolutely a great point because I think in this world of everything “smart:” smart thermometer, smart this, we talk about ease and convenience and all these great things, but patient beware, right? You have to understand that all this “smartness” also comes with a lot of insecurity.

And so the same way you won’t leave your front door open, we really shouldn’t leave these kinds of things so open and vulnerable as well.

So Nakia, Ron, sort of, he did mention the guide. So I know that you all released this Securing the Telehealth Remote Patient Monitoring Ecosystem Practice Guide. Our team, the IEEE SA Transforming the Telehealth Paradigm Group, read it once it was released. We saw it was a bunch of great diverse companies involved in helping you guys create this project.

So can you share with us the supporting laboratory project around it? What was the idea? Was it tested in the lab environment to actually get to the final guide? Share with our audience the making of this guide.

Nakia Grayson
We get so pumped up when we have the opportunity to share our work. It’s great to hear that IEEE has found our work very useful. So the use of healthcare delivery organizations, HDOs, rely heavily on telehealth and remote patient monitoring (RPM) capabilities to treat patients at home. That has increased.

And some of the reasons why, is because RPM telehealth service is convenient and cost effective for all parties. And that’s the HDO, the telehealth provider, and patient. And one thing that we always want to share is that there are many actors in the RPM environment and that’s the HDO, the telehealth provider, and the patient.

So in our practice guide, we assume that the HDO’s engaged with a telehealth platform provider that is a separate entity from the HDO and patient. The telehealth platform provider managed distinct infrastructure applications instead of services. The telehealth platform provider, they will coordinate with the HDO to provision, configure, and deploy the RPM components to the patient home. Also assure secure communication between the patient.

We analyze the RPM ecosystem risk factors by applying methods to describe and our NIST risk management framework. We leverage the NIST cybersecurity framework and our NIST privacy framework, and other relative standards to identify measures to safeguard the ecosystem. In collaboration with healthcare technology and telehealth partners.

We built out a RPM ecosystem and a laboratory environment to explore methods to improve the cyber security of a RPM. So we brought in different technology from vendors to build out this lab. In our practice guide, we make a note that the application of people, process, and technology is very important in having that risk mitigation strategy.

So in our practice guide, the benefits that we stress is that we want to help an organization ensure the confidentiality, integrity, and availability of a RPM solution and enhance patient’s privacy and limit HDO risk when they are implementing a RPM solution.

Maria Palombini
I know that the telehealth guide was really thinking about the RPM in this environment. And this is where we are right now, but we know the trend. We hear it coming about bringing hospitals to the home and everybody’s thinking, this is the future. But how can the work of this practice guide be either applied in some form to address what we think is going to be a huge appealing, uh, cybersecurity appetite for the hospital at home concept?

Ronald Pulivarti
We’re a non-regulatory agency, right? So our practice guides are free for using it as a guidance for especially our targeted audience of these small and large scaled organizations. The way our practice guides are carved for folks to use, we have three different volumes in our practice guide.

We have our Volume A, it really talks about our executive summary of our remote patient monitoring. Then our Volume B is pretty much good for the actual overall architecture. It provides our approach, the architecture, the security characteristics. And then Volume C is really our how-to guide. We provide detailed instructions, how to implement our solution.

One of the things you touched on that’s very important is what was it back then to where we’re going to now. Telehealth is gonna be a very near to never going to go away type of technology. We’re gonna be utilizing this forever until something else new pops up. But I would highly encourage the folks to visit our website.

Our website is nccoe.nist.gov. So it’s nccoe.nist.gov. We have our practice guides that are listed for folks to take a look at and our remote patient monitoring practice guide is there. And Nakia has touched on it, it has valuable bits and pieces of information on the types of work that we’ve actually done specifically for this project.

Maria Palombini
Absolutely. Actually this podcast series, season two was all about cybersecurity and connected health. And all of my guests from around the world really never said it outright, but every time I asked them the question, it seemed like more, they were addressing the issue in the form of mitigation of risk in the connected health system.

So when we talk about cybersecurity talking more security or the mitigation of risk? The idea of a solution that someone’s going to develop someday can never be breached. Is that too much pie in the sky idea?

Nakia Grayson
I really like this question. As we sometimes look at these things as being different, we believe that we’re talking about the same thing. They work in conjunction. So privacy and security work hand in hand. Cyber security is more focused on the physical devices and privacy is focused more on the data.

But I think we’re talking about the same thing. You just really want to get to what is the best thing that we’re trying to provide? What are the solutions that we’re trying to assure that HDOs and small companies can do? And one thing that we mentioned is our practice guide is a great tool to be used to improve cyber security and posture and potential data risk when it comes to the telehealth ecosystem.

Maria Palombini
Absolutely. We didn’t go too much into privacy in this conversation, but they do go hand in hand for sure. Ron, what do you envision as the next best steps in attempting to better secure and protect this RPM ecosystem? We’re seeing more devices enter the healthcare sector with all these cool, smart features such as AI at the edge, that are not only gonna do monitoring, but at some point they’re going to make autonomous decisions without a human intermediary. So I imagine the risk level just goes up a little more in those kinds of scenarios.

Ronald Pulivarti
That is absolutely correct. One of the big and most important pieces here with the project and as we’re entering into new devices in our own home or different environments is understanding those risks with that architecture. We provide our privacy framework, cyber security framework, our risk management framework.

There are so many opportunities for learning to understand that level of risk. And one of the other pieces here is ensuring that your HDO as you partner with the right telehealth platform provider to extend that privacy and cybersecurity control deployment management and efficacy. One of the things that are out there is we’re constantly evolving in technology.

So you need to consider future technologies that can augment data communication safeguards. Also Maria, I will end off on this last note, which is important. Our website, we are actually pushing more and you touched on the word AI. We’re exploring so many different capabilities that are out there within the national cybersecurity center of excellence that consumes not just our remote patient monitoring piece, but we have different areas within our center. We have 20 active projects, for example, over at our center that we’re constantly looking for collaborators in. So one of the things that when, and if folks get the opportunity is again, check our website and look underneath the security guidance tab. And you have different areas by different sectors that we are looking for collaborators in.

We publish information out. We look for feedback as your comments are very valuable for us to constantly improve our information as we’re rolling it out for consumption. So take a look at that underneath again, the security guidance tab, we have different sectors that are available and as we’re evolving in different types of technologies and those areas of interest, we have our practical, usable, repeatable guides that are there and also we love feedback. So there’s a community of interest distribution list under each of these sectors. Do register. Be part of our experience to help improve our current infrastructures that exist today.

Maria Palombini
Absolutely. Last season was AI for Good Medicine. We had so many great different use cases and ideas there. We’ll make sure our guests and our audience are aware of these other opportunities at the NCCoE.

You guys have shared so many great insights with us already. You know, the guide I think is awesome.

I’m gonna pose this question to both of you and I’ll ask Nakia to go first. Any final thoughts you would like to share with our audience as it comes to developing remote care technologies under the context of patient-centered care? Any interesting upcoming projects, plans of action? Things just to think about in general? What is your parting final thought Nakia ?

Nakia Grayson
So I would say that if you haven’t already checked out a RPM Practice Guide 1800-30, we definitely would encourage everyone to read it, check it out. And if you have any project ideas to contact our team. We would like to mention that when we published our RPM practice guide, we also published two tip sheets focused on telehealth. One is for the patient and one is for the provider. Each tip sheet includes a couple of strategies on what each can do. As far as the patient, the provider, to mitigate cyber security and privacy risk or other telehealth services.

And I’ll turn it over to Ron to share about upcoming projects.

Ronald Pulivarti
Thanks, Nakia. Yeah, Maria, we’ve actually had two great virtual workshops. We had one just recently was the virtual workshop on our smart home integration project. The turnout was phenomenal. We had a lot of speakers. We had technology providers, health delivery organizations there to contribute, and we had an open panel discussion. That was wonderful.

Aside from that, we also had our exploring solutions for cybersecurity of genomic data. That was a two day workshop we had. We provide a lot of information for individuals that are registered in our community of interest for each of our different sectors, register! As we have more and more virtual webinars, and hopefully sooner than later physical workshops together. We send out communications and we post it on our website. So register for a community of interest so you’d be notified whenever we have our webinars or workshops. You will also get the opportunity to be part of our draft guidance for the public to consume and provide feedback. You’ll be notified whenever we need comments. So please do so. A lot of these projects that we do here, we try to make it very informative for people out there that actually need to have some type of guidance or some type of framework.

And because we’re such an organization where we rely on collaboration, it’s very important to get people to get involved with us. So once we’re in our labs, once we’re together, we can really do a deep dive and really figure out where these problems reside in which we can actually provide some type of output for a solution that folks outside of our lab can actually, um, use.

Maria Palombini
Absolutely. I mean, I subscribe when I get those updates as well. The IEEE SA volunteers and various projects have responded to NIST calls for feedback and that kind of thing. So for our audience, whether you’re with us or you’re on your own, definitely we are in many ways involved in trying to help the overall global community address these big challenges that we’re facing.

Ron and Nakia, thank you so much for joining me today. It’s been an absolute pleasure.

For all of you out there. If you wanna learn more about all the work going on at the NCCoE at NIST I say, all roads lead to the website, nccoe.nist.gov. All the information, as Ron and Nakia mentioned, is free for you guys to consume. I think it’s a great resource if you’re in this space, whether you’re technical, you’re innovation, you’re a clinician. I think it’s valuable for anybody to read it.

A lot of the concepts we talked about today are addressed in various activities throughout the IEEE SA’s Healthcare Life Science Practice.

Our practice is really engaging multidisciplinary stakeholders from around the globe who openly collaborate. They build consensus and develop solutions in the form of open standardized means to support innovation that will address these issues of privacy, security, and equitable, sustainable access to quality care for all.

Some of our programs: Transforming the Telehealth Paradigm Industry Connections Program and WAMIII, which is where both Medical IOT Interoperability Intelligence cuts to the core of a lot of the discussions we were having today. If you’re interested in learning about these projects and all the other areas we’re involved in, you can visit ieeesa.io/hls.

So if you enjoy this podcast, we ask you to share it with your peers, your colleagues, through your network. This is the way we can get these important discussions and ideas out into the domain, is by helping us get the word out. Be sure to use the #IEEEHLS or tag us on Twitter @IEEE SA.

Special thank you to our audience for listening in, continue to stay safe and well until next time.

Maria Palombini
Welcome to the IEEE SA Re-Think Health Podcast Series. I’m your host, Maria Palombini. I am Director Healthcare and Life Sciences Global Practice here at the IEEE Standards Association. This podcast takes industry stakeholders, technologists, researchers, clinicians, regulators, and more from around the globe to task.

How can we rethink the approach to healthcare with the responsible use of new technologies and applications that can afford more security, protection, and sustainable, equitable access to quality care for all individuals. You can check out our previous seasons on ieeesa.io/healthpodcast.

So as a result of the recent pandemic, the term telehealth has become a frequently used one and it does not appear to be going away. The reality is the way we see telehealth today will look very different. Telehealth is manifesting in many different forms. It’s more than what we commonly see as the doctor patient exchange on an audio/video platform.

It is so much more than that and continues to evolve with innovations in RPM, remote patient monitoring. The telehealth experience has changed the patient’s expectations on healthcare services. They’re relating to it more of a concierge level of online retail experience: convenient, appropriate, and personalized.

And then there’s this growing RPM space. There’s so many different forecasts when it comes to RPM, anywhere from 150 billion U.S. Dollars by 2028 to estimates of 40% of patients using one or two more of these devices at one time. But one thing is for certain, regardless if we are talking telehealth, mobilized health or RPMs, the future of delivering healthcare is not confined to a facility.

It will need to be patient-centered. Season four of this podcast series, Telehealth’s Quantum Leap into Patient-centered Care, talks to the innovators, the winners of the IEEE SA Telehealth Virtual Pitch Competition, the industry leaders, the clinicians, and other researchers who are at the forefront of driving innovation with solutions on accessibility, human factor design, flexibility, security, inclusivity, and all the other necessary ingredients to migrate healthcare to a patient-centered care system.

So just a short disclaimer before we begin, IEEE does not endorse or financially support any of the products or services mentioned by or affiliated with our guest experts in this series. It is my great pleasure to welcome Dr. Keith Thompson, Chief Medical Officer of NuraLogix Corp to our conversation.

NuraLogix was one of the nine finalists to make it to the pitch round of the IEEE SA Re-think the RPM Machine Virtual Pitch Competition. NuraLogix is an AI-powered solution for instant health and wellness data from your smartphone. I love this line on their website, so I’d like to share it with you all. It says: take a selfie to know you’re healthy.

And obviously Keith will share with us what that means. But in the meantime, one of the reasons why I really enjoy having Keith on this podcast is that he is co-leading a Pre-standard Work Stream, entitled Virtual Care Lexicon in the IEEE SA Transforming the Telehealth Paradigm Industry Connections Program.

So Keith, welcome to our podcast!

Keith Thompson
Thank you. Great to be here today. Really appreciate this opportunity.

Maria Palombini
Keith, you have a very well-established career in primary care as a family physician. You are an advocate for utilizing virtual care and telehealth to reach patients. You have demonstrated passion in helping patients in everything from WONCA, the World Organization of Family Doctors, but really what inspires you about the opportunities of virtual care? Most doctors are slower to technology adoption and you seem to embrace it so well. How did you get involved?

Keith Thompson
Thanks, Maria. I’ll be honest. I was really a late bloomer to technology and I jokingly say at this stage of my career I haven’t a lot of time left, so I have to make the best of it, but just seeing the advancement of technology and where workflows were going and how we were embedding this into our day to day encounter just really fascinated me. And obviously you start to see ways of doing things better.

Maria Palombini
Like they say, better late than never. So I’m so glad you migrated to it.

Keith Thompson
Yeah, absolutely.

Maria Palombini
So can you just briefly share with our audience the goal of the work that you had started with the virtual care lexicon work stream? Are you looking to standardize and how will it positively impact the future of telehealth and virtual care?

Keith Thompson
I came to IEEE as a clinician. So just to clarify, I’m not an engineer by any means, but love what it has done just hanging out with this group. It’s an interesting combination of the humanistic and sort of the artisan form of interacting with patients, but that zero room for error and an effort to try and make things perfect. The lexicon that was started really under the IEEE Telehealth Industry Connections that I came to, not really knowing what I was getting into, initially, it has become what started as an attempt to define telemedicine, both technically and use cases and specifically terminology.

And I see where we’ve moved more recently is into that realm of culture and linguistic appropriate services. How do we make this encounter better for the people that we’re trying to engage? And so how we can use that ICT, you hear that term Information Communication Technology, using it in healthcare, but an effort to connect both the materials for health and device literacy, the other area we’re getting into. It’s connecting those educational materials on a system like GUDID, the Global Unique Device Identifier Database, and there’s really a disconnect there. So we realized the first step within the lexicon, we hope to eventually get to a PAR in this class or culture linguistic appropriate services and, or the health and device literacy. Both of those are getting traction.

We’ve begun to explore some collaboration here in Canada, actually with indigenous communities. There’s some interest in the language resurrections and the standards that might result in making that telemedicine encounter culturally safe for first nations. And this is a huge part of what’s going on here in Canada, as we’re in the midst of reconciliation within our indigenous community.

So a project like this within our lexicon really might not only provide an output for standards around connectivity and databases. And what would this look like? So we can share that information with others, attempting to do this, but here in Canada, be incredibly healing, part of a supportive measure just to make telemedicine or virtual care culturally appropriate specifically for indigenous communities.

Maria Palombini
I think that’s a fascinating project and it can transcend many different ways across geographic and other aspects as well.

You went from doctor to Chief Medical Officer of a cutting edge technology company. So NuraLogix uses AI and machine learning, and it offers patients this ability to take a selfie and determine their level of wellness. Just for our audience, what exactly is it monitoring? What area of the population pool does it really serve and what makes this platform so unique?

Keith Thompson
I’ve recently come to NuraLogix and my background was within telemedicine. I’m a primary care doc first and foremost. So my day job is seeing patients. So my side gig was boring and trying to get some telemedicine endeavors off the ground.

We had a working relationship with NuraLogix and I was immediately fascinated. I was like, wow, this takes telemedicine to the next level. Being able to grab patient parameters and some biometric measures within that encounter. So the technology is a novel form of RPPG called Transdermal Optical Imaging and TOI is our trademark terminology. So by capturing blood flow, using that principle of reflected light, we’re not just measuring one region with TOI. We’re actually measuring 21 regions in the face and each region of the face acts differently. Your cheeks behave differently than your nose and your forehead.

So we’re able to capture that pulse wave form and then do feature analysis using machine learning models that are trained on 40,000 patients. And we can capture those patterns in the data sets that allow us readings on over 40 to 30 or more parameters for patients being scanned. So we’re able to capture vital signs, metabolic biomarker risk, cardiovascular risk, mental health stress related to HRV variability, and metabolic risk for diabetes of lipids. So our blood pressure is really our crown jewel. We are engaged with the FDA in a pre-submission. So our claims on this measurement still have to be validated as we get into that territory of class two medical devices. So you’ll see a disclaimer everywhere for investigational purposes only.

That’s really why we’re about to start clinical trials. We’re pretty confident with the technology. We’ve published data verifying that we can meet the ISO 81060 standards. And so can claim accuracy on that. And we have also published some data on our biomarkers of mental stress. The population that we’re serving really the intended use is to screen for risk factors and chronic disease states, under the care of a physician.

We’re not trying to replace the lab or replace the doctor encounter, but just build that awareness. So our solution can really identify if you’re at risk for cardiovascular, hypertension, diabetes, mental stress, heart rate variability and so many metabolic risks as well that we capture.

We’re soon going to launch hemoglobin A1C, an elevated morning fasting blood sugar. So it’ll be a classifier model. Yes, no. Are you above or below a certain level? And if you look at the World Health Organization, it really identifies hypertension type two diabetes and mental stress. Those leading causes of morbidity mortality.

You can see that we’re focused with our solution on those major epidemiological indicators for NCDs, you’ll hear this term Noncommunicable Diseases, and that’s really the big push. So we want our platform hopefully to be available to as many people as possible so they can understand and just be aware of their own health risk.

And we hope to identify those populations at risk before disease develops or its related complications. So the first step in health literacy really is awareness and that’s where we intend our tool to be used.

Maria Palombini
I think that’s really important. And I think you already touched on a misconception that we often hear, oh, I’m using these wearables and it’s monitoring me. So maybe I don’t need to see the doctor as often. And it’s like, no, this is supposed to be in support of.

Keith Thompson
Yeah, yeah.

Maria Palombini
So yeah, important. And it comes right from the doctor’s mouth. We hear a lot about patient centered care and patient centered this in the healthcare system. So when you think of remote patient monitoring devices, systems transforming, or trying to get to this patient-centered care system, where do you think there’s more attention needed or innovation needed to really transition RPM into a true patient centered care model?

Keith Thompson
Honestly, so many things come to mind. I think for me, and really I have to give IEEE and some of the mentors I’ve been working with credit for this, but the first thing that comes to me is equitable access. So what we’ve seen such a digital divide in society is we become more technology based. Yet those social determinants of health in which you hear about have really also become digital determinants of health.

They’re one in the same. The UN declared internet access as a basic human right, almost 10 years ago and we’ve made great strides in improving connectivity in internet access, but there’s still significant disparity, especially within those low middle income regions and marginalized populations where it’s either complex care needs, high urban density or folks with disabilities.

So the application of monitoring systems to the patient point of care, I think will move care closer to the patient in terms of capturing data. But then what sort of ecosystem and workflow are we creating in conjunction with the physicians embedded into that remote patient monitoring workflow and will we see the need for physicians in that workflow at all?

Will patients still want some sort of humanistic attachment and I’ve been diving into a thought leader here; she’s since passed away Ursula Franklin. She was an archeologist by trade, but released a whole thought process around technology. And she talked about technology being either prescriptive, right?

There are rules that you must follow or humanistic or holistic. And really medicine, when you think of it, certainly primary care, is holistic. So how do we combine those two things? And how much can we transfer over to the technology side and at what cost are we losing the holistic aspect? Also, just to comment that healthcare access really is only 25% of those health outcomes. In other words, getting access to healthcare doesn’t solve those issues around social determinants of health, which play a far bigger role in health outcomes. So improving those social determinants is needed, providing the technology or access to care just with technology may not achieve that end result or outcome that we’d expect.

So I think remote patient monitoring also points us to an era of high volume and low physician touch, which I say physician specifically, because there’s another technology thought leader here, Marshall McLuhan kind of another philosopher. He said that the age of technology will be the age of do it yourself.

That’s so true and we see as the knowledge in technical skills are now prescribed or advanced to systems. It could be a Google search to determine my symptoms or at some point AI or machine learning control of robotic surgery or diagnostic systems we’re already seeing. I think there’s a lot of unanswered questions as things go forward, but equity of access for sure is a key ingredient we have to maintain.

And I think that’s what IEEE and SIGHT and HAC have really been focused on and really passionate about. And it’s been great working with this group.

Maria Palombini
Absolutely. It’s really interesting though, you mentioned the social determinants of health. In season three, AI for Good Medicine, I actually interviewed the CTO of Closed Loop AI and one of their core projects on COVID 19, like the effective risk and outcomes was using data of social determinants.

The idea was to really look at the social determinants rather than just therapeutic risk based factors that really improve the outcomes.

So we prefaced this a little bit, but there’s a lot of misconceptions around, you know, remote patient monitoring devices. You know, patients are not going to adhere, the data can’t be validated, this thing is only gonna do so much. When you think about it, what do you see or what do you think is one of the biggest misconceptions when it comes to the concept of telehealth, whether it’s from a patient perspective, a physician perspective, the payers, or any other stakeholder in the process?

Keith Thompson
I think I may be biased from where I am as a physician, but for me, the biggest misconception might center around workflow. For telemedicine to be truly sustainable for physicians and payers, for that matter, it needs to be efficient and optimized in terms of workflow. So this means it supports both patients and providers so that they’re both literate and trained in the pre-visit, during the visit, and post-visit follow-up. What does that workflow look like? How much can we do digitally? Via surveys, questionnaires is a translator needed, is connectivity appropriate? What digital modality is best video or telephone, and does a patient have access to that modality?

I feel there’s some misconceptions maybe from payers, just how much time is involved in a good telemedicine encounter. So even without telemedicine, EMRs (Electronic Medical Records) have significantly increased physician admin burdens, right? The time we spend, we see so much greater integration of technologies to improve the depth of that encounter and using virtual care tools, but we increase the clicks, the log ons several minutes added to that encounter. So how do we cover that added admin time with limited healthcare budgets? So we’re expanding the non-clinical part of that encounter. There’s a disconnect really between the system designers and payers and patients’ and providers’, real world experience.

So payers, providers and patients that digital journey that everyone goes through to access and provide care experience firsthand, go through it. Co-design is so important. Right? So what’s the actual experience for all these actors coming into the system?

Maria Palombini
Absolutely. And I think these are all relevant points, because we all think, oh, we have a new technology tool. It’s gonna make everything go faster. But the transformation is not just the technology, the digital side of it. It’s the whole process that has to be aligned with it. Otherwise maybe we’re just making more work for all of us in the process.

So I often say, I write about this, I talk about it that the future of telehealth will look very different than we see it today.

As a physician, I think for you, why is it important to envision a potential future of mobilized care? We hear about the tele ICU in the future, the mobile urgent care units, but this idea of bringing healthcare to the home, how do we really see it improving patient outcomes?

Keith Thompson
It’s an interesting question, Maria, and I think the question really challenges us to look more closely at telemedicine virtual care and its applications under the same lens that we would use for other interventions, i.e. Pharmacoeconomics right. We talk about human economic outcome or health economic outcome research and cost benefits, cost effectiveness, cost utilization cost minimization.

So cost minimization, assuming that the outcomes are equal, but we can deliver care cheaper or maybe there’s benefits in terms of lower hospitalization. So you can see moving patients into home. Absolutely, one or two days saved from a hospital admission saves thousands of dollars or reduced ER visits. Cost effectiveness is more in actual natural units. So would an intervention, lower blood pressure, and there’s studies on this, right? By partnering with patients digitally, you can prompt them to take their blood pressure meds, to exercise, behavioral change, and we can see effective gains. Lastly, cost utilization, that’s quality adjusted life years, and that’s harder to put a dollar value on, right.

Is that ease of, of access, not having to travel to the doctor and, and all that. That’s convenient. So I think we have to be careful that not all care transitions to virtual in a cost effective manner, we might, for example, see physicians order more needless tests to compensate for that insecurity, a lack of an exam.

And some studies have hinted at this. On this angle, patients might feel that seeing more than one physician just due to ease of access. And I had that counter, you know, with a patient coming to see me and saying the video assessment wasn’t really an exam doc. I needed somebody to listen to my lungs. Right. So we had two visits that could have been done in one. I think we’ll need to apply a little tougher if you look at the economic lens and it makes everybody cringe because we know the convenience. We know the patient’s love of, of ease of access and lower costs for physician encounters. For sure. But in the global economy, what does it look like?

Yeah, we may have to be careful.

Maria Palombini
Yeah, absolutely. We kind of just touched on this before, but we hear of oh, we’re bringing healthcare into the home. Right? Do we really still need doctor’s offices and hospitals and you sort of just led into that. But the real question is, how is that dynamic changing in this area of healthcare? Right? Like thinking of the hospital as the place to go for care.

Keith Thompson
There’s so many forces at play here. And certainly there is in the medical system and physicians, especially in primary care, we want continuity and longitudinal relationships. The patients want convenience of access in some ways opposing forces. Right? So I, I believe the hospital’s always gonna be the go-to for surgical treatments, radiotherapy, for example. But days in the hospital will no doubt be shorter. And I think the post-operative timelines move into the home with less inpatient time. So the question, or perhaps the danger is, is going more into remote patient monitoring and home based care. How far is a physician interaction with its patients removed from that digital ecosystem?

You saw one of my recent posts on LinkedIn, right? With an RPM system that got hacked. You could do a whole thing on security. I’m sure. All the actors weren’t notified, but the poor docs and nurses involved for that remote, fetal heart monitoring, the system was down.

Nobody knew. Patient didn’t know, physicians weren’t notified, and there’s gonna be a really messy lawsuit as a result. The other part to this, how much of that face to face is therapeutic, and really can’t be replaced by a digital workflow. And I’m not sure we know the answer to that yet, but there’s one person that can tell us and that’s the patient. Just, as I mentioned before, about Ursula Franklin, you know, that prescriptive force of telemedicine and remote patient monitoring becomes so strong that this becomes now the only way of doing things. And so i.e. that digitally and remote patient monitoring fewer face-to-face visits, but how holistic and compassionate is that healthcare system, will it be at that point?

We can, yes, have ISO 9000 perfection and supersede that need for human touch and interaction with patients, you know, how far do we go and who knows, certainly this is where we need to dig down. I think a bit more and perhaps further research on patient reported outcomes and satisfaction and not just healthcare dollar saved.

Maria Palombini
Absolutely. And I think it’s an important point that we always talk about stakeholder trust and everybody thinks well, will the patients trust the process and the device, but we also need the doctors and the clinical workers to trust it as well. And so if workflows are not designed to best mitigate risk for all the parties involved, then we’re gonna continue to have this question of trust.

Keith Thompson
I wish honestly, every one of my colleagues could at least do a couple of stents in some of our meetings to learn about that issue. I trust that my device is measuring properly. I have no idea the standards and the protocol for that trust. And I can think differently about calibration now and how I approach, you know, just simple measurements.

Maria Palombini
So we’re kind of leaning into this question here and I think you mentioned it as well earlier on, this question of health equity, right. We know there’s marginalized populations without access to healthcare, or very limited access to healthcare or understanding of the healthcare process. So telehealth technically right should reach those who are the hardest to reach.

Keith Thompson
Yeah.

Maria Palombini
So Keith, in your view, how can telehealth equitably reach the patients who are currently not included in the healthcare system. What do you see as some of the challenges that need to be addressed? Obviously you mentioned the language was one, but that telehealth could be a viable platform to try to close this healthcare gap.

Keith Thompson
As I mentioned earlier, those social determinants become digital determinants. They become one in the same in my opinion, but apply that technological access to a marginalized population doesn’t unto itself, improve an outcome. Certainly, access I think is the cornerstone. We’ve gotta have a secure line into those communities and it should be a basic human right just as clean water and food security. And beyond this, I think then we look to focusing or leveraging community health workers within those communities. You know, we’ve had some presentations here with IEEE Public Health Foundation of India and Dr. Aaron Jose and their telemedicine program.

Look it up, doing some great work, partnered telemedicine with community workers, right. To be that line in. We partnered at NuraLogix with LaFiya to put telemedicine kiosks into remote regions of Nigeria. What’s interesting about that platform is the solar panel that they put in that community is being used as a resource to provide some micro economies that might be the alternative business model, because really the issues move away from solving the connectivity to solving those social innovations and business models to support those regions. So there’s no longer value in the model of just selling devices and multiple units to providers or consumers rather, how do we fund a single device and platform and scale to regions needing support for tens of thousands of patients without access to primary care. The technology’s great, but we really have to keep our eyes on the ball I think on the sustainability and business model, because it’s certainly talking about compassion and humanitarian reach. I think you’re sort of assuming that it’s for free and it’s, you know, NGO and it’s a philanthropic offering, but there’s ways to do it right. That we can support communities with technology and help them sustain themselves.

Maria Palombini
Absolutely. Very, very good. All right. So Keith, you’ve given so many insights. I think your perspective as a physician working in a really technical environment is really, really refreshing. Any final thoughts you would like to share with our audience? It could be technologists who are embarking in virtual care technologies or already there and looking at this context of patient set and care, it could be a call to action, a call for attention and innovation.

Keith Thompson
Yeah. You know, really honestly, just to say thank you to you and IEEE, right? That industry connections and SIGHT, this organization has been an incredible mentor and inspiration for me.

I’ve said that combining engineering design with zero error and medical humanitarian applications, right? Compassionate care here has been an incredible journey. So call to action. Get involved in this organization, if you can, you’re gonna grow personally and professionally. And I guarantee, you know, become a better person just by helping address those needs of humanity using technology and last thanks to NuraLogix for supporting me in this right.

They’ve encouraged me, no questions asked. I love it. So great. I really appreciate Maria. Thank you.

Maria Palombini
Thank you, Keith, you always got so many great insights, your passions, and, you know, for humanitarian causes and just overall, just your empathy for patients. It’s just very refreshing.

So thank you for taking the time and being part of this podcast today.

For all of you out there, if you wanna learn more about NuraLogix, you can visit nuralogix.ai. If you would like to get involved in the work stream, Keith mentioned virtual care lexicon, or other aspects of the IEEE SA Transforming the Telehealth Paradigm Incubator Program, visit ieeesa.io/telehealthic.

Many of the concepts we talked about today with Keith are addressing so many different activities here at the IEEE SA Healthcare Life Science Practice. You know, the mission of the practice is engaging multidisciplinary stakeholders, such as Keith and they openly collaborate. They build consensus and develop solutions in an open standardized means to support innovation that will ultimately help us achieve the goal of privacy, security and equitable, sustainable access to quality care for all.

Activities such as the Transforming the Telehealth Paradigm, the WAMIII, Wearables and Medical IOT, Interoperability Intelligence are just naming a few of the different activities here. And if you wanna learn more, how you can get involved, there’s no cost to join these activities, you can visit ieeesa.io/hls.

If you enjoyed this podcast, we ask you to share it with your peers, your colleagues on your networks. This is the only way we can get these important discussions out into the domain is by you helping us get the word out so you can use the #IEEEHLS or tag us on Twitter @ieeesa, or you can tag us on LinkedIn @IEEE Standards Association when sharing this podcast.

So a special thank you to you, the audience, for listening in today and continuing to stay safe and well until next time.