AHLA's Speaking of Health Law
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AHLA's Speaking of Health Law
Digital Health Care for the Cognitively Impaired
Tara Sklar, Faculty Director, Health Law & Policy Program, University of Arizona James E. Rogers College of Law, and Kathryn Huber, MD, Kaiser Permanente, discuss the prevalence of cognitive impairments as the U.S. population ages and the implications this has for the future of digital health care. They cover the legal and regulatory landscape and issues related to privacy, informed consent, coordination of care, and reimbursement. Tara and Kathryn recently wrote an article for AHLA’s Journal of Health and Life Sciences Law on this topic.
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Speaker 2:This episode of a HLA speaking of health law is brought to you by A HLA members and donors like you. For more information, visit american health law.org.
Speaker 3:Well , hello, great to be with you today. Uh , my name is Tara Slar . I am the faculty Director of the Health Law Policy Program at the University of Arizona, James Z. Rogers College of Law. And I also hold an appointment at the University of Arizona College of Medicine in Tucson with our Arizona Telemedicine program as the Associate Associate Director of Telehealth Law and Policy. And I am so excited to be with you today , uh, along with my co-presenter, Dr. Katherine Huber, who I'll have , uh, introduced herself .
Speaker 4:Hi, everyone. Uh, I waived for those of you who can't see me, <laugh>, it felt right . Uh, uh, my name is Catherine Huber, and as Tara mentioned , uh, I collaborate with her. And I am a professor of practice at the James EE College, a James E. Rogers College of Law, a University of Arizona as well. I'm also a practicing , uh, internist at Kaiser Permanente in Denver, Colorado. And I also hold an appointment at the University of Colorado School of Medicine , uh, where I teach bioethics , uh, for the medical school. Um , so like Tara, I wear several hats as well. And , uh, we're very excited to share with you our recent work and our , uh, collaboration because we do quite a few of these. And , uh, if you can't, can't tell from our backgrounds. We, we think that we cover quite a broad area of interest to, to multiple people, and I'm excited as an internist to be on this podcast and share with you my clinical experience.
Speaker 3:Oh , that's great, Catherine. Thank you. Um, so Catherine and I just read an article , uh, with the , um, American Health Law Association, journal of Health and Life Sciences Law. The article is called Regulating Digital Health Care for the Cognitively Impaired. And , um, I thought before we we're not gonna go through the article bit by bit. It's there for you to access at any time, and we're more than happy to talk about it. But , um, we thought we'd just do kind of a general overview about the motivation for this work and some themes really intersecting with both law and clinical practice that we think are important to note, particularly at , at this time. Um, before we get started, I just thought I'd also just to kind of explain our collaboration that , uh, Catherine and I have had for a long time, several years now, when she was , um, a graduate student at, in her final year of medical school at the University of Arizona. Uh , we met about ethics meeting where I had been talking about technology and assisted living. And afterwards she came up and she was like, I've been looking for you. And I said, I've been looking for you <laugh> . And we just like grabbed hold of each other. And so as a result , um, uh, you know, Catherine's, even though she's in Colorado and she still teaches , uh, uh, the program, she teaches a course on technology and , um, what's the name of your course? Catherine Technology and Aging
Speaker 4:Technology and Aging , uh, legal and Ethical Development Development
Speaker 3:<laugh> . Right . Um, so, so that's a big part of our intersection of our work. Um, uh, and what was behind this particular article that we wrote for the Journal of Health and Life Sciences Law was, you know, really thinking about the prevalence of cognitive impairments, because I feel like as a generally , um, you know, it seems to go from either, people think it's just part of the aging process, that as you get older, your mental faculties aren't quite as strong with , um, memory and executive function and, and , and , uh, or you actually do develop some type of dementia, particularly Alzheimer's, Alzheimer's disease. So , uh, when Catherine and I were , Katherine and I were talking about this concept, she really explained to me the idea of the continuum impairments . And that seemed to have a lot of , uh, weight, how we think about digital healthcare and how we would integrate , um, telehealth and other ways of providing care at home, depending on where someone might be on this cognitive impairment continuum. So, maybe I am jumping ahead a little bit, but I maybe it would be helpful to hear from Catherine , um, exactly what the cognitive impairment continuum continuum is, because that was pretty instrumental to us wanting to dive deep in terms of digital healthcare and then how we regulate digital healthcare .
Speaker 4:Uh, yeah, yeah. Happy to kind of talk through that from the clinical perspective. Um, 'cause maybe it's not something that's familiar to all of our listeners. Uh , what we mean by cognitive impairment continuum. Uh, so for us, we, we kind of define that as the spectrum from mild cognitive impairment, all the way to the other end of the spectrum of dementia. And kind of what does that mean, having that spectrum, what the mild cognitive impairment , uh, end of things. Um, people may notice that they're having some issues with their memory. They may feel like they're forgetting small things here or there. They may have a family member who says, you know, you , you seem like you're forgetting a lot. Uh, and where I see this clinically is either the patient will come in for an appointment, for a memory evaluation, or , uh, they'll come with their family member and they'll say, you know, mom or dad, or, my husband's been forgetting a lot lately, what do we have to do to check his memory? So, mild cognitive impairment is something that , uh, can be objectively assessed with a variety of clinical tools. Um, but there's also a definite subjective component of people , uh, feeling like they're forgetting things or having , um, kinda early stages of memory issues. Um, for a lot of people, mild cognitive impairment never progresses beyond that. And that , that's oftentimes what people think about when they think, you know, some memory loss as we age. But for another huge portion of the population, people do progress , uh, through the stages to the end of the spectrum, which is dementia. Uh, and dementia is de defined as memory issues, plus something. So plus a functional impairment or plus , uh, behavioral changes plus , uh, something else clinically and objectively that matters. Um, and similar to the mild cognitive impairment end of the spectrum, and something we can objectively assess and quantify , um, most people are familiar with the most common form of dementia, which is Alzheimer's dementia, but there's quite a few different types , um, and kind of taken all collectively , uh, it is a huge burden both nationally and internationally of people that it impacts. So, WHO estimates that maybe 55 million people worldwide are impacted by Alzheimer's and related dementias. Um, and the US alone, this accounts for up to $1.3 trillion of healthcare spending. Um, so it's, it's a big issue , uh, for those of us thinking at the policy and population health level. But then on the individual level, it is massively impactful to patients and their loved ones , um, and the people who take care of them . Um, so that's kind of a , an overview of what we mean by the cognitive impairment continuum. So for us, we're talking about that range from mild cognitive impairment, so memory issues, no functional impairments, the other end of the spectrum of dementia memory issues, plus functional impairment. Um, and for, for kind of further evidence of, you know, how prevalent this is , um, the Alzheimer's Association estimates that two outta three of every American will face some level of cognitive impairment by the age of 70. So even if you're 69, <laugh> about to turn 70 , uh, or if you're 21 about to turn 22 , uh, this may be something that impacts you in the future or impacts those around you. Um , so it's something I see every day . I take care of predominantly older adults and complex , uh, patients. And so at , at least every day , I'm taking care of somebody with a , either a mild cognitive impairment or dementia. Um, and for many people, it's present in their day-to-Day lives, or present in their work in some capacity. So , um, uh, I'll , I'll kind of pause right there. <laugh> , maybe , uh, pass it back to Sarah , uh, kind of how we arrived at, you know, talking about this particular population and why we think it presents such a, a great opportunity, I think about technology and healthcare in part because of the burden, as I mentioned, the prevalence. Um, but also because they represent a very vulnerable , uh, uh, group of the population , um, that has some really unique challenges. I think we need to figure out if we're gonna effectively and efficiently implement technologies in our healthcare of years to come .
Speaker 3:Oh , what a fantastic overview. That's great. Thank you. Uh , so that clearly explained the prevalence of it . And then we have had, because largely because of the COVID-19 , um, public health emergency, you know, we just saw this huge shift in being able to provide more remote care in the home. So folks that were somewhere on the cognitive impairment continuum, you know, may have an more than ever an option to not have to come in for the classic 15 minute in person doctor visit, if they could do that over the phone or through some type of telehealth messaging patient portal. Just what an enormous , um, shift in that individual's , uh, quality of life for both them and their caregiver just to have the option to not have to go in regularly to manage medications, to have , um, certain tests done, just to have a check-in. So , um, that was really inspiring in terms of, you know, really improving someone's quality of life. And then if we think about , um, a lot of the emphasis on digital healthcare and virtual care is calling it pandemic resilient. So that was, that was a big issue too. Like, you don't want individuals who are, who are frail, and often people with a cognitive impairment, particularly further along on the continuum, we'll have other co comorbidities that could lead them to be immunocompromised to another infectious disease as well. So just what are the options we're really going to help address this population , um, access virtual care in a more seamless user-friendly way. You know, how do we get there? Where's the law enabling it? Or where could it be acting as a barrier? So that's, that's , that's pretty much what we honed in off this particular paper. And , um, and there's, and I just wanted to flag that there are a lot of fantastic resources in this area, one of which is the center of Excellence for Telehealth and Aging, which has these age inclusive principles when it comes to virtual care. And that is that it's person centered, which is a lot of what we've been thinking about in terms of how all these technologies develop and where someone might be in the continuum. 'cause we really don't have quite enough evidence at this point to know exactly what the standard of care should be given this wide range. And , and so that , that was the point we wanted to hone in on. And because that, how do we get there? And one way that we would get there is like, well, are there the proper incentives there? Proper incentives, meaning is there reimbursement? Is that something that can be relied upon? So we kind of interweave throughout our article and throughout all our body of work on just kind of coming back to, you know, how do we best meet the needs of this population and, and to help us visualize this in a way that I hope will become clear on a podcast as we created , um, a fictional vignette , uh, represent represented representative patient of this population that we're describing. And her name is Cora, and we've highlighted her now in several of our articles and presentations. And I'll turn it over to Catherine to describe , um, who Cora is this fictional patient, and , um, how she helps us continue to identify, you know, where, where virtual care is intersecting with her , um, ultimate quality of life and accessing care from her home and going forward.
Speaker 4:Yeah , so <laugh> as, as Tara mentioned , uh, we, we've kind of really leaned on this case example that we've named Cora. Uh, for me, coming from a clinical background, there's always a , a patient example or a patient clinical vignette that we're using to kind of teach various complex medical concepts. So this was a very natural exercise for me, <laugh> . Um, and so when we're thinking about our patient, Cora, we'll say she's, you know, a 80 or 90-year-old woman who has a variety of comorbidities ranging from diabetes to , um, chronic obstructive pulmonary disease, or COPD. Um, when we first kind of meet her and introduce her in our article, we are are interfacing with her as somebody who has a mild cognitive impairment. So sometimes has some issues remembering to take her medication , sometimes , uh, forgets to , uh, confirm her upcoming doctor's appointment or forgets her doctor's appointment. But overall, she's able to do most or all of her activities of daily living and independent activities of daily , daily living, which for those of you who aren't familiar, include things like caring for oneself, toileting oneself, cooking at home , um, taking medications, managing finances, the things that you kind of require to do to make it through your day as a independent adult , uh, <laugh>. And , uh, so we meet her when she has some level , uh, of some memory challenges, but it's not quite yet impacting her function , uh, when we think about how telehealth might be used for her. So these are the patients that , um, we can still do virtual appointments with, schedule her for a , either a Zoom call or a phone call to check in on how her COPD is doing, check in on her inhalers. Um, and that's a great opportunity for us as clinicians to see, you know, in the background of the zoom call, what kind of state is her house and who's in the home? Does she have pets? Is she using her oxygen during the appointment? Um, so it provides a wealth of opportunity for us as clinicians to really optimize her health virtually. And she doesn't have to spend the, sometimes, you know, 2, 3, 4 hours it takes to get from her house to the car, to the appointment, check in , wait in the waiting room, see the doctor, check out , go to the lab and make it back home. She can do , um, her appointment from home and from the comfort of her home, save those hours a day that it may take her. Um, and we can really, you know, offer the exact same, if not, you know, better quality of care at home. Um , so that's where we first interface with her as somebody with mild cognitive impairment. So these are patients that can still use wearable devices pretty effectively. Usually they can learn how to use a new technology , um, or they can be involved with their family members. And how do I , um, you know, use this home blood pressure cuff, or how do I use this remote scale to check my weights every day and upload those to my provider? As we kind of move through our article And, and as we've discussed in other places , um, as cognitive impairment progresses, the ways in which they interface with technologies changes and their needs change quite a bit. So most people are familiar with , um, the concept that as cognitive impairment progresses, people will need increasing levels of support , um, and care either at home, which is where most older adults would prefer to be, or , um, eventually transition transitioning to a more institutionalized setting. So , um, maybe unlike other chronic conditions, cognitive impairment , um, can result in quite a bit of , uh, care requirements, specifically custodial care requirements in addition to kind of healthcare management requirements. Um, as those activities of daily living and independent activities of daily living start to decline and dementia progresses, so the person's ability to care for themself or to toilet themself , feed themself , that that is a known kind of loss of function that will occur , occur over the progression of the disease. And so , um, when we think about Cora , fast forwarding on average, you know, seven years is the time to progression for Alzheimer's dementia from co mild cognitive impairment. We fast forward seven years , um, and Cora now requires quite a bit of assistance at home. She's fallen quite a few times. She's having a really hard time taking her medication. She requires them to be distributed to her to take , um, she , uh, is not necessarily , uh, the safest in terms of managing her own house. She's left the stove on, she's left the water running. Um, and now we're seeing a huge opportunity in the technology space for kind of automated , uh, automated , uh, pill dispensing. We're seeing, you know, the rise of things like the ring camera in home monitoring devices to keep an eye on the stove, to keep an eye on the running water, things that her family members or her care team or whoever is caring for her can utilize to try to keep her safe at home or keep her safe in the space that she's in. Um, and then , uh, you know, thinking about, you know , where her or care is occurring, she can probably still do some of those telehealth visits or appointments, but now there's gotta be somebody who's there to operate the technology with her. So for a lot of people with cognitive impairment, their ability to continue using, you know, the zoom calls or the phone calls to , um, complete their telehealth visits becomes much, much more challenging as the disease progresses. And this is where we see family members or , um, caregivers or care team members have to step in, provide the camera, work the camera, work the phone , um, provide a lot of the context and information about the patient. Um, and the patient is much less of an active participant. Um, and so hopefully I've highlighted some examples along the way in which technology is being used to provide care , um, for older adults as they age across the, the continuing ranging from the beginning, pretty independent functional use of these technologies To the end, they're a little bit more of a passive recipient of these technologies. Um, so maybe I'll pause there and, and <laugh> give Tara the time to talk. I'll stop talking about chorus so much that represent so many patients that I see and , um, for many people what their loved ones go to. Um, but I'll , I'll kind of pause there and pass back. And we can think about, you know, maybe how, Tara maybe you can comment on how are these technologies currently regulated? What are they , uh, what are the opportunities that we have for them?
Speaker 3:Sure. And I think what's important about this conversation is we're talking about us as individuals as we get older, but also our, our networks, our caregivers are , um, either unpaid and paid caregivers that are , are part of the , we're describing and also how that intersects with technology. Yeah . So our overarching question for Cora that's been guiding a lot of this work, I'll just read it for our audience here, is how to ensure years lived , the cognitive impairment are dignified in human years, supported by a system designed to maximize patient's values and needs with accessible options to age at home. Because ideally, what we absolutely wanna avoid and we know is inevitable, is to be in a situation where someone's has, you know, maybe a little further along than MCI, but you know, they could go home, but the family's at a loss of what to do. The physician doesn't quite know what to say. You know, there's just this like no man's land of like, should they go to assisted living? Should they go home? What if they come back? What if they , um, and so you end up with this like delay stay in either the hospital or in a rehab facility where they might deteriorate, the patient might deteriorate even further. So just to avoid all those costs and , um, harm that could happen , uh, uh, as like , and when, when we know that these are inevitable situations that we're gonna keep finding ourselves in. So , uh, with that in mind , um, you know, we, the way that virtual care is currently regulated , um, uh, coming out of the public health emergency is, you know, we still have these temporary , um, extensions in place, but are , which are said to expire at the end of December, 2024 , um, where , uh, patients are able to access care from their home. Those geographic restrictions were lifted. They don't, you don't have to live in a rural or provider under , uh, underserved area to access virtual care. Um , Medicare reimburses for it in your home. They reimburse for it if it's gonna be audio only . Um, you know, there's also , uh, uh, there's also flexibilities in terms of having acute hospital care at home through certain hospitals and programs that have those as well. So all these , um, virtual care options are currently available under Medicare and , um, those incidences, but they're temporary. And, you know, they are set to expire end of December. Predictions are that the latest is that now by the, in the, after the election in the fourth quarter of 2024, they may get extended for two more years. The exception to that would be the acute hospital care at home program, which may be extended for an additional five years. That just goes to highlight for you that there's an enormous investment that clinicians and providers and hospitals and health systems undertake as they're trying to not only have the technology infrastructure in place to care for patients in their home , um, but to, to take on that financial risk and not know if they're gonna be able to continue a program that won't be reimbursed, is where I think we're seeing a lot of these delays. So , um, you know, in terms of having a very , uh, and thinking about this from a , a user pers end user perspective, knowing where a patient might be in this cognitive impairment continuum, like what devices and wearables, like, how should it be scaled up with this technology to, you know, help ensure that overarching question we had for Cora, where she really is able to maintain her independence and quality of life for as long as possible. Like, I feel like there's a lot of unknowns. Like every day there's more and more studies looking into it that their pilot studies , um, they're, they're all over the board. I mean, I , I think Catherine could maybe speak to this as a clinician. Like, how do you even, like, where do you begin the process of determining , um, you know, if the patient is gonna go home, like how you can continue to see them virtually, what, what to have in place in their home types of checklists. Like we have that for the acute hospital care at home program, I think lots of hospitals are developing, and you mentioned this earlier, like check the environment limit hazards. Like, you know, is it , is it clean? Is it , um, uh, are there ways in which the patient or and their care caregiver will be able to , um, you know, maintain a nice, clean, safe environment for the patient to be in as they either get better or continue to live there? But it, it feels very ad hoc from a legal perspective based off what I've seen in terms of state by state , um, you know, what's being reimbursed and what isn't, which is different from Medicare. Um, uh, and so I just wanna get Catherine's perspective on that. 'cause it, it is , um, what do you do?
Speaker 4:Yeah, yeah . You bring up some really great questions. Well , you know, one part is, you know, coming out of the hospital, so say core is admitted for A-C-O-P-D exacerbation, or she falls coming outta the hospital, you know, as we've seen with the , um, acute care at home or the hospital at home programs, we're able to get people out of even the emergency room back home , um, where they want to be and do that pretty safely and effectively, and managing their medical conditions, kind of optimizing things. And that's been a great option for a lot of patients. Most patients don't wanna be in the hospital. The food stinks. You're up all night, you're being poked constantly , uh, and you can't sleep. Um, and it's especially dangerous for patients with cognitive impairment 'cause they're at much higher risk for falls and for delirium , uh, which is a huge issue in healthcare. Uh, and so everybody kind of agrees from the patients , providers, can we get these people home sooner? That's definitely an optimal way to go. And so the, you know, reimbursement structures and the infrastructure that's been built to allow for hospital at home has been tremendous in helping this particular population. I mean, tons of patients post covid and during covid, but definitely for this particular population, this is a huge win. Um, and then the other thing you brought up is, you know, who do we actually get technologies in the home from? And that's when it becomes a little bit more, you know, like Amazon shopping <laugh> of what you wanna send them home with. So the other scenario is, you know, me as a outpatient provider from primary care, somebody is telling me that they're following once a week or every few weeks. I'm thinking, man, are there any technologies that I can use for false detections? Can I have them , you know, that everybody thinks of the life alert. If they fall, how are they gonna call for help? Um, but there's a lot of different things that we could potentially use to manage other conditions like COPD, heart failure diabetes is a huge one with all the continuous glucose monitors , um, that are coming out. But a lot of these are kind of cherry picking what technologies are available. And for most technologies that are available , um, and you can speak to this, most are not reimbursed by insurance. You know, it's pretty limited. Um, despite the massive explosion of technologies that are developed and advertised to patients and available , um, that there's just not a ton that I can actually prescribe as a clinician for my patients to go home with, even if there is emerging evidence that they can be helpful. Um, and there's a ton of new research coming about , uh, coming out for, you know, home monitoring devices or , um, accelerometers in the watch to help kind of detect falls or mobility challenges. But a lot of that I, I can't order for most of my patients. They'd have to buy it on their own, which presents a pretty big challenge in terms of both who's able to access it. There . There's a variety of manufacturers all with different instructions and different metrics and different evidence supporting their use. And then, you know, in terms of equity, a ton, a ton of these technologies are just priced out for the average consumer. Um, so <laugh>, there are options to me, but , uh, what are the best options? Most clinicians are pretty in the dark , uh, about what we should be doing and what we can be doing. So, you know, the hospital at home provided a great , um, example from maybe how we can bundle things and think about things and deploy them. But for a lot of other situations we're , we're still lagging. And we can talk about some other examples besides the hospital home. But , um, it's been a huge challenge <laugh> , um, and , uh, yeah, to , to your point, you know, the reimbursement is , is a big barrier to that.
Speaker 3:Yeah . Yes. And so this , um, I guess this is like the, the point in which , uh, all the , all these scenarios that you've described and the frustration and the , uh, inevitability of how they're just gonna continue to increase, like, we know from our demographics that we currently, the, the oldest part of our population are those who are 85 and over , uh, within 15 years. By 2035, that population's gonna double from being currently six and a half million to nearly 12 million. So, <laugh> , all these scenarios that you're describing where you're sort of at a loss, or is it gonna be equitable or is this gonna work? I mean, this is, this is like, this is what you would call a train wreck. Like, you know exactly what's gonna happen. And , um, and yet where we are in terms of treating these patients and their families to get the kind of care they need in the optimal way, the most efficiently, safely, and their preference. Um, so, so just how do we allocate our resources to more appropriately meet this need that we know is gonna be there? And so that, that was this big question that we've had , um, overarching all this work, <laugh> ,
Speaker 4:<laugh> for years, we've been trying to answer this question.
Speaker 3:So we, we also approach it different in different ways , um, in my law background, and Catherine also has a master's of bioethics, you know, thinking about this from broad , like that's just a legal regulatory compliant angle, but also, you know , um, really how do you obtain informed consent, particularly from a population that may , uh, not be able to provide that. Um , and also for when you have all these continuous monitoring devices, implications for all that data, all the data that's being collected, stored , shared , um, potentially sold. Um, so we, we talk , we talk about issues of consent, we talk about and relatedly privacy. Um, and then , uh, before I go on too far , um, uh, the other one I wanna just tag for Catherine to also address is coordinations of care. Because this is a population that has multiple providers , um, you know, how that works in this space as well, if they're trying to receive all their healthcare needs from the home. Mm-Hmm, <affirmative> . So , uh, why don't we perhaps , uh, go through those three, if that's all right, Catherine , get your perspective on it, like how to handle consent, privacy. Um, we don't get too into all the different shades of privacy happening right now across the states. Um, but you know, that is something to certainly be aware of , uh, especially as Le State legislators become more and more concerned about the amount of health data that is being sold to third parties without patient's consent. But I'd love to hear your thoughts because , because the , because that at the cornerstone of consent and privacy really is trust, trust in your provider trust to receive the care you need. So how, with the population experience and cognitive impairment, how to think about informed consent and privacy and coordination of care. Um, I'd love to get your thoughts.
Speaker 4:Yeah, I , I mean, I think this topic is a , is a goldmine for discussion and opportunity. So I'm very biased in that this is what, you know, gets me excited to go to work every day . <laugh> is talking about how do we fix these things? Um, but informed consent is, in my perspective, a a big challenge. Um, you know, as I mentioned earlier with people are on the more mild cognitive impairment end of the spectrum, you know, for most of those people, they're able to give, you know, adequate informed consent to use of different technologies. But certainly as their , um, condition progresses, we may lose that capacity. Um, and right now there's not a great model or a great , um, example of kind of, should we be thinking about informed consent for some of these technologies in those earlier stages when they have mild cognitive impairment? You know, can we think about documenting or having those conversations of, if you were to develop dementia down the road and couldn't answer these questions or participate, you know, independently as fully as you can today, would you be okay with us putting cameras in your home if that meant you could stay at home longer? Um, would you be okay with us, you know, putting a , a wearable on you to detect if you're falling, if that meant that we would also know where you were at all times. For some older adults , that's gonna be a yes. 'cause their ultimate goal may be to remain in home and to avoid in institutionalized care. And honestly, for a lot of my patients, that's their biggest fear is ending up in something like a memory unit. Um, so those patients, they may say, absolutely, whatever technology you need to use, let's use that. And then we can talk about those risks . But for other people , um, that, that isn't in line with their goals or their values , um, and, you know, kind of equally important to the individual that we're gonna, you know, try to have those conversations with is their family members, because some of these devices are capturing information on family members as well. So if somebody has cameras in their home to watch them , if they fall, it's also gonna capture data on, you know, their loved ones who are coming in and outta the house to check on them , or care providers who are coming in to, you know, assist with their ADLs and ADLs. Um, and , and, you know, we don't have a good model for how we're gonna cover consent to use these technologies and what to do with that information and that data that's being stored and collected, as Tara mentioned, with third parties most of the time. Um, and to my knowledge there, there isn't much , um, infrastructure or structure yet as to how and if that data could be, you know, contained under a HIPAA protection if it's in their home. And if it's from a third party or a commercial device, then no. Um , but if it's something that links to their care team provider me as their clinician and flags me that they've fallen, does it, does it become HIPAA protected information? And if those are questions that we have to answer , um, because it will impact, I think, how these technologies are being advertised to patients <laugh> and, and how companies plan to profit from them and the data that they collect. And , and there's a huge amount of gray area in those spaces. Um, so , so definitely informed consent to me is a huge deal. Um, and, you know, it's not that all patients with, you know, dementia can't give informed consent, but there has to be a little bit more, you nuance to it and obstruction how we're gonna have those conversations when along that continuum. And, you know, can somebody with a advanced dimension give ascent to the use of these technologies? We don't really have a model or example for that yet , um, as opposed to other things related to their healthcare. Um, and that, that kind of tags along, like I mentioned, we're capturing data on them and their family members, their care providers and, and issues around privacy, and how is the data being monitored and stored and safely protected for patients. Um, and like I said, I don't think we have a good answer for that yet. Um, and I think, you know, some of the examples that we have are from, you know, like the ring camera systems , um, that are monitoring kind of outside , um, but there's nothing that we've really kind of tested or piloted inside the home or in these intimate spaces of people's lives when we're trying to optimize their care. And the goal is a little bit different than, you know, security to make sure your Amazon packages aren't stolen or you know's knocking at the door. Very , very different situations.
Speaker 3:Um , yeah. Yeah . Go ahead . Lemme interrupt . Go ahead. I was just thinking, that reminds me of other themes that we , um, tangentially talk about in this work. Um, one of which is how technology could be contributing to greater rates of social isolation and loneliness. Mm-Hmm . <affirmative> , as people rely on technology more and more, there could be less , um, in-person visits by clinicians coming to the house, like only if there's a problem that they come in, otherwise they'll just look at the data. Um, and just how that could lead to less communication by someone experiencing a cognitive impairment, you know, they more interaction is , is very, very helpful. So how to do that either through technology with some interactions or just something to be aware of as we rely more and more on , um, virtual care Mm-Hmm . <affirmative> and not having in person interface. And the other thing that I think has been quite striking that we've talked about a little bit in our work is this potential false sense of security. Like, when you don't really know where someone may be on the continuum, like it's such a gradual phasing from , like , they seem pretty independent, but all of a sudden, like they leave the stove on or they , um, uh, can't seem to, you know, get up on their own or they're , they don't know they , they're outta sorts , um, a little bit with like their surroundings. And so I think it's interesting on some of these wearables or devices like , you know, know there's button options to like push this button, but if you don't know what the button's for and you've Mm-Hmm, <affirmative> , you know, you've fallen or you are in a situation that you don't know what's going on or , um, you know exactly , uh, how to get ahold of a , your doctor Mm-Hmm . Or a loved one, but you have this button <laugh> , like that's not just because you have a button <laugh> . Yeah . Just because you have the technology doesn't , it doesn't mean that you will a push it or know what will happen. So I do think like there's a very two very real concerns as we roll out technology more and more in the home in addition to everything we're already talking about is, you know, will this lead to someone being, you know , more isolated with us just pushing technology on them to monitor their needs And , um, and is that technology safe? Like, will they know how to use it depending where they are on the continuum? Mm-Hmm.
Speaker 4:<affirmative> . Yeah. I mean , the success of, you know, an alert system requires the person to know they have the alert system and how to use it <laugh>. And for this population one day, that may be the case the next day it may not be. And um, you know, a huge gap here is that it's not ne they're not all created equal and most don't interface with, you know , the emergency personnel or their doctor. They just go straight to, you know, their next of kin. Oh
Speaker 3:Yeah .
Speaker 4:Or yeah, or you know, maybe they do call 9 1 1, but they didn't actually need, you know, fi a fireman in their living room to pick their up
Speaker 3:Or an ambulance. Yeah. My mom , my mom has the Apple watch, not to name names. Yeah . But like, and like she plays tennis a lot and every time that she , um, something happens and like the , anyway, the watch says that she has fallen like with high false, false positives, much higher frequency than actually occurs . You just imagine if like the emergency services is notified every time that occurs and you don't know enough to know that you need to turn it off.
Speaker 4:Yeah. I mean, other examples, the Apple watch will flag there , you're having an arrhythmia. Oh , right . The Apple watches are, you know, really good evidence that they can detect things like atrial fibrillation. For some patients, that's really dangerous for other patients. That's how they live their life every single day and they're fine. Um, but it doesn't do anything when it flags you, it just tells you <laugh> versus, you know , if they're having an actual dangerous arrhythmia or, you know, the other kind of in-home monitoring devices like the blood pressure cuff, your blood pressure's too high. They don't do anything after they tell you <laugh>. Like , it'd be great if they would just call the nurse line or, you know, call 9 1 1. Um , but there , there's no like , uh, you know, guardrails or safety features on some of these technologies. Well,
Speaker 3:I think there's real implications for that in terms of the overall adoption rates. And we've talked about this too in our work is if , um, let's say an an older adult, you know, is really turned off by like the number of bells going off notifications, and they don't want to, like, this could be an indicator they don't wanna use this type of technology because it's very disruptive, it's rattling. Mm-Hmm. <affirmative> , um, it makes them feel like we've been quotes by , um, in other articles, qualitative studies where it makes them feel like a prisoner Mm-Hmm . <affirmative> like , they're like , um, Catherine and I have looked at , uh, bed alarm , bed alarms in particular, which has a really big impact on potential health outcomes because patients will be so scared of setting off the bed alarm should they move Mm-Hmm . <affirmative> that they'll be afraid to get up and exercise and all those things that you should do , um, when you're in a, in a rehab or trying to recover from the fall Mm-Hmm . <affirmative> Or just in general <laugh> day-to-day movement. Um, and , uh, if you have technology that effectively makes you feel paralyzed or overly monitored , um, or you may be also another element is that folks may be scared that if the technology watching them somehow detects that maybe they aren't safe to be on their own, that they'll have to move out of their home. So like, so these options in terms of , um, turning off the technology when needed, opting out, stopping recording, like, you know, where that intersects with patient's preferences to do so, but also how that could potentially impact , um, you know, the ability to effectively monitor their care. Mm-Hmm.
Speaker 4:<affirmative> . Yeah. And , and it's really not clear to the user end of things, kind of how to address different preferences for settings or notifications, right? Aside from just not using the technology, we're kind of in an all, all or none , uh, space right now. And, and maybe we shouldn't be, maybe we should have the capacity to better tailor it to values and preferences.
Speaker 3:Oh, I love that. That is such a great segue. The all or none versus like, how do we tailor it to what , uh, uh, uh, what we do have years of fantastic studies on with virtual care is with the veterans Mm-Hmm . <affirmative> Health Administration. So , um, Catherine's quite a bit experience looking at the va, and , um, I thought I would just let you talk about that for a bit . <laugh> going forward, you know, we do have examples of where the reimbursement's there certainties there, this, you know, infrastructure care population. So we can see, we can see how it could be successful , um, to get at those questions of not all or nothing, but how to really personalize this virtual care in a way that is achieving these very effective health outcomes and cost savings. So I'll let you talk about that for a bit, if you don't mind.
Speaker 4:Yeah. Yeah. The, the VA is a great example of kind of longevity and sustainability and how to integrate some of these technologies into healthcare and , and do so sustainably. Um, the VA's kind of telehealth program was first kind of kicked off in the early two thousands, around 2003 . Um, and it's, it's been a very excellent example, a very successful example , uh, of how to slowly scale up and how to be able to evaluate, integrate new technologies in , in more real time , um, than maybe in other sectors of healthcare. Um, so the VA relies quite a bit on their telehealth infrastructure , um, because they do have a really large , uh, population of patients who are either home bound or in rural or underserved areas where it's very challenging for them to get , uh, to physical locations for their care. And telehealth has really helped to increase access , um, for most of those patients. And today, you know, approximately 40% of veterans receive some form of telehealth care as part of their just general healthcare . Um, the big areas that I, I think are amazing just from kind of what I do on a daily day space , but the big areas that they use, telehealth care and primary care , uh, chronic disease management and mental health care . But, you know, over the last five to 10 years, they've also expanded that to subspecialty care, and covid was a huge impetus for that , um, as well. Uh, but they also have services through, you know, wound care and geriatrics and palliative care, you know, spaces where you'd think in person only, but it , it's, they've really shown that it can be done virtually. Um, they , uh, do use quite a few of new technologies , um, as part of their model , uh, that they're able to deliver to patients, which is kind of my ideal <laugh> to one day be able to do , uh, in kind of all spaces of healthcare. But, you know, they're able to prescribe a home blood pressure cuff that will sync with their clinic and be integrated into their system, record those blood pressure readings directly into the chart. Um , it can flag, you know, a nurse line if something's out of whack or , um, you know, on a dangerous level. Um, so blood pressure's one example, but the , um, kind of home , uh, scales is another example. They also , uh, are able to deliver, you know, iPads , um, or other kind of technologically tech , tech tech, that's what I'm trying to say, <laugh> , they can deliver the technology , uh, to the home , uh, for people who don't have access to it. And they've made a part of their model assessing for , uh, digital health inequity and being able to provide and close that gap for a lot of veterans and , and making sure they have the technology or have access to the internet , uh, or broadband that they need to utilize these technologies. Um, and they partner with me , some select carriers to be able to , um, to offer this service. Um, so it addresses some of the gaps that we see in other spaces , um, in , in a really holistic and integrated approach. And it's not just cool , um, it's also very cost effective for them . Um, and, you know, as a system that focuses a little bit more , uh, explicitly on quality of care and patient outcomes , um, they , they've really kind of walked the walk and talked the , walked the talk that they do , um, <laugh> , uh, to, to meet those outcomes. And so , um, they've seen huge , uh, uh, benefits in terms of chronic disease management and diabetes and obesity and hypertension control. Uh, they meet those metrics pretty effectively when they utilize their telehealth services in those spaces. Um, and uh, then I mentioned, you know, cost savings , uh, since the program's inception, I guess a little over 20 years ago now , um, it's estimated they've saved $2.8 billion , um, with even, you know, 30 40% of their members enrolled in utilizing the services, which is amazing. Um, so when we're thinking about the population that we worry about and talk about a lot, Tara and I , um, all , it's a very high use, high need population. Um, that level of cost savings and that level of improved outcomes is not negligible. Um, and so I think that the VA gives us a great model of, you know, ways that we could do that successfully, but obviously the incentives are a little bit differently and the structures differently. And there is, you know, attention and priority given to making sure infrastructure and safeguards are addressed, which I think we can learn a lot from <laugh> in , in , in other areas. And, you know, looking at Medicare, Medicaid and potentially in the commercial space eventually as well.
Speaker 3:Yeah, absolutely. I think it , it sets a , an example to follow , um, uh, you know, going on since 2003, I believe you said it was launched in Yeah. Um , of what's possible. What if we get the , um, reimbursement in line, the incentives, the guardrails, like the , this is just not the only restricted to veterans. We are seeing all of some movement, which you and I referred to in the article with different, what different states are doing with Medicaid waivers, which is pretty exciting. Um, but, you know, they tend to be, you know, kind of pilot waivers like looking at diabetes specifically, or hypertension, remote monitoring for physical care. You can see , um, you know , different states doing different things for the dual eligibles, those on Medicaid and Medicare. That's another kind of population to watch , um, you know, outside of the VA and , um, in terms of really how to expand this technology into, for a wider, wider use. But I think we could , we , we , I think we've outlined pretty well the , the , the prevalence , um, the high need. Um, you know, this is all coupled with , um, a severe workforce shortage when it comes to, in-home care. Uh, we're already at half a million workers , uh, demand for home health aids to help in this space. And, you know, as I've mentioned earlier, with the number of folks living to 85 and over, expected to double the next 15 years , um, the demand for home health aids is gonna continue to surge. In fact, there's that, that one job that has , uh, more openings than any other occupation in the US right now. Mm-Hmm . And it's projected for the next 10 years. So that's how much of a reliance on technology we have going forward. And then all these gaps that Catherine and I have been discussing over the past hour , um, I think really highlight how far we still have to go. But there are really, really fantastic examples in place with the VA and lots of experiments happening with states looking at Medicaid waivers in this area. Catherine , is there anything else that you'd like to add before we let our user , let our listeners go?
Speaker 4:Yeah, I, I mean, there's just so many different things to talk about in this space. Uh, and we could spend another couple of hours. They would let us <laugh> <crosstalk>
Speaker 3:Association , it's like <laugh>.
Speaker 4:And then I was like, oh, wait, we do, we have, you know, a whole , a whole program that we have University of Arizona that we dedicate, you know, just to this. So obviously, like we care a lot about it. Other people are talking a lot about it . There's a lot of movement in the literature. And, and even though there's a lot of areas of concern, maybe we sound like Debbie Downers on some , uh, aspects of it, there's so many opportunities for improvement and, and growth. And for me, it , it comes back to what can I do to optimize the values and, and the health of my patients like Cora, who represents somebody that we see. Um, 'cause for me that's at, at the heart of all of this is what, what can I leverage in the years to come to, to give them the care that they need and the care that they want. Um, and, you know, working with people like you, <laugh> Tara and the HLA, hopefully that's how I get those things from my patients <laugh>.
Speaker 3:Oh, that's great. Yeah, I think just really spreading awareness about how we really aren't there and what we're seeing in clinical practice and how it varies across the states . These are just exactly the messages we're trying to get out. Yeah . So thank you for your time today. Thank you to our listeners. Um, please feel free to reach out to us by email. We'd love to chat with you more if this is a topic you're interested in. Uh, warm thanks and appreciation to speaking of health law and the American Health Law Association.
Speaker 2:Thank you for listening. If you enjoyed this episode, be sure to subscribe to a HLA, speaking of health law, wherever you get your podcasts. To learn more about a HLA and the educational resources available to the health law community, visit American health law.org.