State of play: Health care after the pandemic

The regulations that could shape tomorrow's health care

In March, President Trump signed the CARES Act, which contained the largest economic stimulus package in the nation's history. The $2 trillion bill set aside $130 billion for financial relief for health care operators in the U.S. and relaxed regulations around telemedicine.

In the intervening months, telemedicine visits have gone from a tiny segment of the health care industry to the prime way that many people interacted with their doctors for nonemergency visits. Novant Health went from conducting about 200 telemedicine appointments per week to over 12,000 per week during the pandemic. Global telehealth funding skyrocketed by over 67% in the first quarter of 2020 when compared to the same period in 2019, according to CB Insights, with more than $1.5 billion changing hands in the quarter alone.

"Now that our clinics and physician centers have reopened, we are still maintaining about 2,000 virtual visits per day," Novant's chief digital officer, Angela Yochem, told Protocol. "So even though our in-person volumes are close to what they were before the pandemic, we still see a great appetite for virtual primary care visits and specialty consults. I expect this will increase over time as patients become more comfortable with the model, particularly if the payor community continues to reimburse for those visits."

And those changes, if they stick, are likely to help those who traditionally struggle to get access to health care. "A patient who under 'normal' circumstances takes a one-hour roundtrip travel, waits for at least another 15 to 30 minutes, only to see a provider for 15 minutes, is going to wonder why [he] wasted all that time," Eskioglu added. "Telemedicine is here to stay. I believe a certain percentage of patients in areas such as psychiatry, endocrinology (including diabetes) and dermatology will drive the biggest transformation."

For smaller health care providers without the support of an entire health system behind them, the transition to video has been a bit more difficult but equally as prevalent. The CARES Act created funds for doctors to buy laptops, webcams, tablets and video-calling subscriptions that they might not have had before.

"It provides a lot of the funding for connectivity and the actual medical offices to start adopting the technology, buying iPads or subscribing to Zoom. That funding gets them over that hump of initially using it," Daniel Castro, vice president at the Information Technology and Innovation Foundation, told Protocol.

Beyond the CARES Act, Castro said temporary changes to how telemedicine is regulated in most states have also had a big impact. Most states have said that, for the entirety of the COVID-19 national emergency, insurers can't refuse to cover video visits, and that the rates for those visits should be on par with in-person visits. And in March, the federal government allowed doctors to practice telemedicine during the national emergency in states beyond the ones in which they're licensed.

The relaxed regulations have also allowed startups to operate in more places than before. Companies like Alpha Medical , which offers telehealth and pharmacy services to women across the U.S., and Doctor on Demand , a telemedicine company that does as its name suggests, have seen the number of people looking into their services rise over the pandemic. Alpha Medical CEO Gloria Lau recently told Protocol that she expects many people to continue on with telemedicine calls even after the pandemic recedes. "I think COVID-19's sort of silver lining is that the public is getting a huge education in ways to be creative," Lau said.

There's no guarantee that the eased regulations will stick around after the national emergency expires, but the pandemic has shown the value of, and willingness of people to use, telemedicine services. "That's where there's still a lot of open questions as to whether this will be a temporary boost in telemedicine, and then things will eventually go back to the way they were before," Castro said.

Making health data work for patients

But there's another recent piece of regulation that could end up having an even bigger impact on the future of health care in the United States. In March, around the same time that the U.S. started to grapple with the realities of the pandemic on its shores, the Department of Health and Human Services announced that it had finalized its rules on how patient health data could be easily shared between providers and services, mandated by the 21st Century Cures Act from 2016.

"Interoperability has been pursued by multiple administrations and numerous laws, and today, these rules finally deliver on giving patients true access to their health care data to make informed health care decisions and better manage their care," HHS said when announcing its rules in March, suggesting the timing had little to do with the ongoing pandemic that was about to force millions of Americans into their homes.

The rules essentially mandate that health care providers share any patient data with patients and any third parties that they would like to share the data with, while ensuring that information stays private. Traditionally, health records have been kept by hospitals and doctors, often still on paper, which patients have to call to request sent to other doctors. Even when the data is available electronically, through software offered by companies like Epic, it's often difficult to extract from that system and share with others. The HHS' rulings will require health care providers to develop or buy systems that allow health data to be shared easily, likely with APIs and other modern data management systems, so that patients can access and share their data with other apps they would like to use.

The ITIF's Castro sees a comparison to what the Dodd-Frank act did for consumer financial data after the 2008 financial crash. Dodd-Frank gave consumers the right to easy access to their financial data, which helped give rise to the plethora of fintech startups that have sprung up over the last decade and helped redefine how the country banks.

Certain tech companies have tried to push the boundary of what's possible under existing frameworks. Apple, for example, launched its Health app in 2014, linking with its own Apple Watch wearable to help users track body metrics. In 2018, Quest Diagnostics, one of the largest clinical lab companies in the U.S., started offering patients the option to import their lab results into Apple Health. But beyond looking at your LDLs or HDLs, there's not really much you can do with the data. Theoretically, the white space that now exists is that companies will be able to build products on top of that health information that can flow directly from doctors to patients to third parties, or even right from medical devices to third parties.

The main stumbling block that remains is data that doesn't come from a health care provider, but from consumer devices. There's no federal regulation around how to handle data from an Apple Watch or a connected blood glucose monitor. Federal regulation that allows that data to flow from patient devices to doctors or third parties could change the way illnesses are diagnosed in the future, and where. The pandemic has revealed there's interest in something like this for the long term, but it's not something that will likely be fixed overnight. "Right now you still have state-by-state privacy rules in addition to HIPAA," Castro said. "And I think that does create a barrier."

Castro suggests something like the European Data Strategy, proposed by the EU , where data would flow through a single marketplace for all member states. "The U.S. isn't really thinking about it in terms of how we create national access," Castro said.

But with so many having gotten a taste of the future during this pandemic, a national set of standards for data from devices owned by consumers could drive a revolution in the near future.

Diagnosing and staying healthy from home

A large slice of the U.S. population has been stuck at home for the better part of four months now. And unless we've needed emergency medical attention, we've primarily relied on phone calls and video chats for our health care needs.

But beyond those calls, there hasn't really been much of a way for doctors to see how their patients are doing. None of the poking and prodding, the reading vitals or taking blood pressure doctors do in person is really possible over Zoom. But there are devices — which you might even have on your wrist right now — that could change that, thanks to those HHS regulations and the CARES Act.

Wearables are quickly moving from devices that can tell you how many steps you've walked to products that can accurately tell you about your health. The FDA recently approved the Apple Watch Series 4 and 5, both of which have a rudimentary electrocardiograph (EKG) onboard, to take EKGs for diagnostic purposes. Previously, a doctor wouldn't use a patient's Apple Watch EKG reading, but for the duration of the COVID national emergency in the U.S., they can stand in for a full EKG during a telemedicine call with a doctor. A person wearing a compatible watch can share their EKGs with their doctor. If the doctor sees something suspect, the patient can come in for a full EKG.

It's an early example of how the pandemic is shifting what patients can do in their own homes to monitor their health. Other products on the market, such as AliveCor's KardiaMobile 6L, have pushed the boundaries of what a consumer medical product is. While the Apple Watch started out as a consumer device that has slowly become more medical, AliveCor's products have been designed to make medical devices as easy to use as consumer electronics. The company, founded in 2010, was the first to convince the FDA to allow consumers to even read the heart-rhythm strip produced by an EKG in 2014, Chief Commercial Officer Ira Bahr told Protocol.

"Sometimes the FDA takes the view that there's information [that] when put directly in the hands of a patient, may or may not be beneficial to that patient's health," Bahr said. "Sometimes there are physiological readings — someone might take the view [they] might cause more anxiety than it is worth."

The FDA decided, however, that the data would be valuable to consumers and approved AliveCor's software, followed a few years later by the company's first at-home EKG device. Since then, it's gone on to produce the 6L, its most advanced EKG product to date, which features six connection points that the machine uses to take its measurements, which is half as many as machines in doctors' offices, but still effective at painting a picture of your heart's rhythms; Apple's, for comparison, has two. And it has another benefit: It only costs $149, rather than the several thousands of dollars the full machines can cost.

The device signals a growing trend of products that look and feel like consumer devices but have the power to give useful information to health care providers in everyday settings. "The democratization of medical data is something that we absolutely wholeheartedly support," Bahr said. "Patients' data belongs to the patient."

It may not be long before more gadgets like these start to replace more aspects of diagnoses, to the point where people have a far better understanding of how their bodies are without having to wait to get into a doctor's office for the annual physical — if they even go. There are already devices on the market that attempt to take as holistic a view of a person's health from home, which they can share with their physician, such as TytoHome , which Novant uses. The $300 device combines a small handheld touchscreen with the sensors on your smartphone and can provide live images and vital data to doctors on a telehealth visit. For parents who are worried about a young child, or for patients with limited mobility, it could be a game-changer to get data like this without having to head to the doctor's office.

"It is more convenient and it is generally far less expensive to deliver something at home electronically than it is to cause a patient to go to a clinic for treatment or analysis," Bahr said. "At-home health care is as inevitable as Uber and Amazon."

"Over time, we believe the data from wearables and other commercially available sources will provide an interesting overlay to clinical data, allowing us to identify trends in our patient communities and be very precise in our predictions of major health events before they happen for our patients," Novant's Yochem said.

Some devices have even been used to try to figure out whether someone might have COVID-19 from home. Michael Snyder, chair of Stanford Medicine's Department of Genetics, has been running a database of heart rate data from wearables of people who have opted in to share their data with Stanford. Snyder's team is testing whether they can glean from the data when someone may have COVID by measuring changes in resting heart rate over a period of time. Snyder himself has been using a smartwatch for two years to track his own Lyme disease, telling Protocol that every time he has been sick, the watch has shown an uptick in his resting heart rate before he's shown any other symptoms. "We think smartwatches and rings can be very powerful sensors for when you're ill," Snyder recently told Protocol. "They've very scalable."

Streamlining the health care process

Patients have always wanted to spend less time in hospitals, and the pandemic has only increased those feelings. Meanwhile, the pandemic has laid bare some of the inefficiencies in the system and accelerated the process of change.

Many hospitals postponed elective surgeries as a result of the pandemic, and patients have tended to stay home unless they were truly unwell, according to Aaron Patzer, the founder of Vital, which makes patient intake software for hospitals. But ER attendance has started to creep back up. In Georgia, it's now 75% as high as it was before the pandemic, Patzer said. But the wait times are as high as ever because patients can't share rooms, and COVID cases need to be separated from everyone else.

Vital's software has changed as a result of the pandemic, as well, Patzer said, which indicates the sorts of sweeping changes that need to come to hospital experience. During the pandemic, many people visiting ERs have waited outside after checking in, to help keep their distance from others. Vital added a messaging feature so staff can let patients know when they need to come back inside, as well as a function that can update family and friends about the process, because relatives can't always go with patients into the ER or operating rooms. "You get separated from family members during a time when it's really quite scary," Patzer said.

Using information from hospitals' own electronic health record, or EHR, software, Vital can now pull out relevant information and share it with patients who are often left in the dark during their ER visits today. Without extra work for staff — who are "busy saving lives," as Patzer said — any time a nurse orders medicine, a lab result comes back or a doctor orders a test, the patients can be pinged and be told when they'll next see a doctor.

Patzer compares it to how Instacart or Uber Eats works, bringing a level of consumer product understanding to a market that is often stuck on legacy software. "I'm not saying that we're necessarily doing something that's revolutionary, but it's absolutely never been done in health care," he said. He added that he's had hospital systems request that his system supports IE 9, a web browser that Microsoft launched in 2011 and stopped supporting in 2017.

And it's not just startups that are working on technology like this. Novant's Yochem said that the health system already had online check-in before the pandemic but recently added text notifications for when patients should come back into the hospital or exam room. Eskioglu added that the system has also been scaling back the number of people allowed in waiting rooms, and that the plan is to introduce intake kiosks that can detect if a patient has a fever or is wearing a mask.

"Coincidentally, we had already designed our new cancer center and infusion floors without waiting rooms," Yochem said. "We leverage smart infusion chairs and AI-based scheduling mechanisms to allow patients to come into the facility when their chair is ready and direct the patient back to their chair just as it is ready."

Patzer said that software like his could help cut down on visits to hospitals that could have easily been handled with telemedicine. "There's about 140 [million] to 145 million emergency room visits in the U.S., and it's estimated that maybe 40% of them were 'unnecessary,' at least at least from the insurer's perspective," Patzer said.

One change that Patzer expects in the near future is a greater reliance on software during the intake process. If patients can work with an AI chatbot to figure out what's wrong, leveraging EHRs and information provided by patients, hospital systems can determine what someone really needs. "I see an increased use of artificial intelligence to help make those nuanced decisions," Patzer said. "Because a cough or cold to you or me might not be that big a deal unless it's COVID, but it might be to somebody who has a transplant — being able to ingest all of that and make those decisions is really important."

Patzer said that his co-founder, Justin Schrager, a doctor in Atlanta, sees about 50% of his patients with no information on them whatsoever before they come in, because they haven't been to that hospital before. Even if they usually went to another local hospital, there's no guarantee the patient data would be shared. "Interoperability in health care is still an absolute mess," Patzer said. "It often relies on phone calls and faxes — the one place where the fax machine still is going strong."

In the future, that information could come from the patients' own wearables or health wallet, or some central health repository. But for the nearer future, the steps toward automating patient information and giving doctors as much information as they could possibly have on their patients will still be small. Patzer sees one of the first areas that may soon become more interoperable is the ADT feed — these are essentially lists of patients coming into hospitals, the reason they came in, and their insurance information. It's not an extensive health record, but some states have already started creating "health information exchanges" to share some patient data across the state. There's examples in Wisconsin and Vermont .

Eventually, these will get wrapped up into regional exchanges, and potentially a national one, Patzer said, but the road to interoperability will be a long one. "It's by no means standardized, but it's a start," he said. "It'll be another 10 years before I would say that we have something national is my guess."

Who's going to pay for the future?

There's one other major roadblock to any changes to the U.S. health care system: Who is paying for it.

Kent Ivanoff, CEO of VisitPay, a payments platform for health care, said that many of the EHR systems hospitals bought in the past were designed as tools to allow systems to effectively bill insurance companies.

But after the Affordable Care Act was passed in 2010, the amount owed by patients directly for their health care, rather than from insurers, jumped to an average of 20%, according to Ivanoff. "Even modern, sophisticated players like Epic and Cerner, their technology was largely built in an era where the patient, as the payer, owed a very small fraction of a health system's revenue stream," Ivanoff said. "Those legacy systems were built in a different era to clear claims in bulk."

Much like hospital visits and wearables, the payment process is ripe for greater personalization of information and experiences. And it's an area where patients are expecting change. In a 2016 study, Ivanoff said, the company found that two-thirds of patients preferred to get their statements on paper. "I would argue that was a vestige of a very confusing process between a provider, a patient and their insurance company, and not having an ability to disentangle all of those connection points and being reliant upon paper, because that was the only real venue that those players offered to consumers."

Three years later, 60% of patients said they wanted their statements digitally. "COVID is going to take that number north of 80%," Ivanoff estimated. "COVID has dramatically increased the adoption of technology by patients."

But beyond making bills simpler for people to understand and actually pay, the types of health care people can pay for needs to change. "I think the reason why physicians were slow to adopt telemedicine is the reimbursement structures, for Medicare, for commercial payers, just were not firmly established," Ivanoff said. "It was really unwieldy to get reimbursed by one of the commercial payers: As much as telemedicine was trying to come into vogue prior to COVID, there were a lot of financially induced institutional and structural barriers that really kept that adoption from taking off the way it should have."

Companies like CVS Health, which owns the insurer Aetna, have been attempting to respond to the unprecedented situation. "Since March 1, CVS Health has seen an exponential increase in virtual mental health visits as compared to the same period last year, as well as substantial increases in calls for help with psychological distress including anxiety, grief and loss, and trauma," the company told Protocol. It's been providing no-cost mental well-being and counseling resources for first responders and seniors since then, as well as waiving fees on other products. It's waived cost-sharing for COVID tests, added coverage of telehealth to Aetna Medicare Advantage members, and waived out-of-pocket costs for in-network primary care and telehealth visits through Sept. 30.

But the question remains: Will all the unprecedented changes that have happened in the last few months stick around after the pandemic faces — and will they form the platform for future innovation? For the ITIF's Castro, it's a moment of opportunity: With so many people becoming more accustomed to distance health care, consumers will want a different paradigm than the one they have today.

"I think it's an evolution," Castro said of the telehealth boom's role in the future. "When you have that ease of experience, you're not just waiting six months to see them to ask five questions, then you're like, 'Well, why don't I just email them a question or do a quick chat with them?' I think this pushes us into moving away from the current model of you have your annual checkup and that's it."

Next in Protocol's Health Care Manual: 'Everyone is looking at health care differently': How medicine will evolve after the pandemic .