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Advancing NEMT with Ride Sharing — featuring Megan Callahan of Lyft Business

Blog - 0006

Global Chief Medical Officer, VP of Healthcare Worldwide Commercial

HLTH Team: Tell us about your work – and how Microsoft has responded to the COVID-19 pandemic. Dr. Rhew: When COVID-19 was first reported in China and the infection began to spread quickly throughout other parts of Asia, Europe, and the United States, Microsoft engaged at an early stage to help healthcare organizations and governments worldwide respond to the crisis.   One example, heightened public concern along with a readily transmissible respiratory pathogen necessitated that health systems adjust their underlying processes for screening and triage. Providence, a large multi-state multi-hospital health system with significant presence in the greater Seattle region, applied an artificial intelligence (AI)-based “chat bot” technology developed by Microsoft to address the rising patient concerns about the virus. By asking a series of questions based on the latest Centers for Disease Control &amp; Prevention (CDC) guidelines, the chat bot screened patients for COVID-19 symptoms and/or exposures. Patients with symptoms and/or exposures were subsequently directed to Providence’s telehealth portal for clinical evaluation and possible testing. The bot was facilitating successful and efficient population-level care coordination. This enabled high-risk and/or symptomatic patients to receive a timely remote clinical evaluation, without increasing the risk of virus transmission to other patients or extending the wait-times for those with symptoms. Since then, Microsoft has delivered the same chat bot technology for hospitals and governments across the globe. Today, more than 45 million people globally have been using this bot technology. Early in the pandemic, we also saw hospitals and ICUs overflowing with COVID-19 patients, accompanied by critical shortages in personal protective equipment (PPE), lab testing kits, ICU beds, ventilators, trained critical care specialists, and medical treatments. In response, Microsoft launched and participated in collaborative efforts with partners across the healthcare ecosystem. <ul><li>One example was the collaboration between the American Hospital Association, Kaiser Permanente, Kearny, Merit Solutions, Microsoft, and UPS to launch Protecting People Everywhere, an initiative powered by the HealthEquip™ app through which PPE donors and their donations could be matched with potential recipients. The app ensured the equitable distribution of critical PPE and other medical supplies to the places they were needed most. </li><li>In another example, GE Healthcare and Microsoft joined forces to help critical care specialists do more with their resource constraints by developing and launching a virtual ICU solution called Mural™. The Mural™ Virtual Care Solution is hosted on Microsoft Azure and integrates several disparate critical-care data sources (electronic medical record (EMR), telemetry, ventilator, infusion management, etc.) into a single pane of glass, allowing for remote consultation of ICU patients at scale. </li><li>Microsoft applied its chat bot to facilitate the donation of convalescent plasma from those who had recovered from the illness as part of the “The Fight Is In Us” Campaign. The plasma will be used to help find a potential treatment for COVID-19. </li></ul>Our teams also collaborated with Adaptive Biotechnologies to launch ImmuneCODE which is sharing one of the largest, most detailed views of the immune response to COVID-19 based on de-identified data generated from thousands of COVID-19 blood samples from patients around the globe. Information from ImmuneCODE will accelerate ongoing global efforts to develop better diagnostics, vaccines and therapeutics for COVID-19. Technology has played an important role in helping to battle the pandemic, and Microsoft will continue to lean in to support efforts where technology can make a difference. HLTH Team: What’s surprised you most about the response to COVID-19? What has Microsoft done to help customers push forward in new and different ways?  Dr. Rhew: One of the most notable changes that emerged as a result of the pandemic was the rapid and large-scale adoption of virtual health. The passage of the Coronavirus Aid Relief and Economic Security Act (CARES Act), which provided funds through the Federal Communications Commission’s (FCC’s) telehealth grants program, along with subsequent federal actions to lift technology and reimbursement restrictions previously placed on virtual interventions, were key drivers in fostering the rapid adoption of telehealth services. St. Luke’s University Health Network (SLUHN) provided a prime example of how hospitals were dramatically shifting their ambulatory practices towards a virtual care model. SLUHN, a large regional health system encompassing multiple counties across two-states, introduced and adopted telehealth using Microsoft Teams™ as its virtual care platform. In a matter of days, the health system trained thousands of staff and providers to conduct, document, and schedule virtual visits – fundamentally altering its healthcare-delivery apparatus. Using the platform, they now schedule and evaluate thousands of patients daily.  Recognizing that technology has a role to play in accelerating progress for solutions to the pandemic and other pressing healthcare concerns and challenges, Microsoft accelerated its efforts to develop and launch the Microsoft Cloud for Healthcare. The Microsoft Cloud for Healthcare brings together trusted and integrated capabilities for customers and partners that enrich patient engagement and connects health teams to help improve collaboration, decision-making, and operational efficiencies. HLTH Team: I understand you worked in infectious disease research early in your career—how has that work informed or prepared you to understand and meet the needs of healthcare providers?  Dr. Rhew: Infectious diseases is one of the few specialties in medicine that balances the needs of the patient along with the needs of the community and society. Just as important as prescribing the right antibiotic is knowing when not to prescribe it or when to stop it. As I reflect upon my days as an AIDS physician and researcher, my responsibility was to treat the patient, study the disease, promote education and prevention, and constantly assess the community-resistance patterns of HIV and other infectious agents to the latest antibiotics.  Today, with COVID-19, we are faced with a similar but broader-scale balancing act. Implementing public health measures to decrease the spread of infection and keep hospitals afloat, balanced against the impact that these measures may have on the economy, education, and people’s civil liberties.  Microsoft has taken a very thoughtful and principled approach as to how we as a company would respond to the pandemic. The heart of our response have been guiding principles to put people’s safety above all else as we worked to help our customers and protect our employees.  There’s been a lot of learnings through our efforts about best practices. Some of my personal learnings and best practices I’ll take forward include:  <ol><li>Lead with empathy </li><li>Lean on existing crisis management principles </li><li>Move quickly and move together </li><li>Listen to the experts </li><li>Communicate frequently and transparently </li></ol>HLTH Team: Can you tell us more about the work you’re doing that can transform our response to COVID-19; supporting re-opening and a phased approach to recovery?  Dr. Rhew: Microsoft, along with its partners, have been working on a variety of ways to help support businesses. Those areas span facilities and workforce preparation, management and operations. Microsoft provides Power Platform™ technologies that organizations can use and customize to address all of these areas to meet their needs.  However, for others looking for a fully managed service, our partners have developed programs using Microsoft technology. For example, one of those partners is United Health Group (UHG) and the program is called ProtectWell™. The core components of ProtectWell include: an employee mobile app for self-attestation; employer app to enable facility check-in; and closed-loop COVID-19 lab testing in coordination with major lab testing sites such as LabCorp and Quest. The program started with UHG and Optum employees. Since then, UHG has offered the program at no charge through the end of the year to U.S. healthcare organizations, businesses, or universities. HLTH Team: What’s next for you? For Microsoft? Where do you see us in 6 mos or a year in relation to COVID-19?  Dr. Rhew: A primary area of focus for us at Microsoft will involve exploring how healthcare can be made easier, smarter, and more efficient for patients and providers. Microsoft Cloud for Healthcare, an end-to-end healthcare specific platform, will serve as our vehicle to help achieve this goal. In May 2020, we announced the availability of the public preview of Microsoft Cloud for Healthcare. Through the public preview, we’re working closely with partners across the healthcare ecosystem on key use cases, to facilitate integrations into existing platforms and systems of record, to streamline the workflows, and to ultimately deliver better experiences, better insights, and better outcomes. With respect to COVID-19, we will continue to lean in to help, focusing on helping everyone get back to their places of work or school, which includes our recently launched initiative to help 25 million people worldwide acquire the digital skills needed in a COVID-19 economy. About Dr. David Rhew: Dr. David C. Rhew is the Global Chief Medical Officer (CMO) and Vice-President (VP) of Healthcare for Microsoft. He is the Chairman of the Health and Fitness Technology Division for the Consumer Technology Association and serves on CTA’s Board of Industry Leaders. He co-holds six U.S. technology patents that enable authoring, mapping, and integration of clinical decision support into the electronic health record. David is currently an Adjunct Professor at the Stanford University School of Medicine.

COVID-19 Discussion with Dr. David Rhew

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President

Working with patients on the development of digital health products is an increasingly important topic to maximize patient engagement. In a product development journey, there are multiple points where the patient’s voice must be heard, and guidance such as <a href="https://www.eupati.eu/" target="_blank">EUPATI</a> or <a href="https://www.iso.org/standard/63179.html" target="_blank">IEC 62366 </a>already exists to support the industry to move into that direction. These guidelines promote patient engagement in specific product phases like Research &amp; Development, product usability, clinical trials and testing, Health Technology Assessment or ethics committees. However, in practice, healthcare industry tends to focus more on the output (i.e the solution itself) rather than the value patients can bring when they actively contribute. This article describes several strategies to increase patient contribution in the development of digital health products and considers how to make personalized medicine a reality.  Strategies to ensure patients engagement while developing health solution The first and easiest way to ensure patient engagement when launching in the market is to consider their perspective. Deciphering the patient journey, from the appearance of first symptoms up to diagnosis and therapy prescription stages, understanding the healthcare system in which patients are living, as well as the emotional journey patients can experience, are all crucial for identifying existing gaps in the care pathway to deliver complementary solutions at the right time for the right need.  Once this first step is achieved, it is important to make sure that the needs of the patient, as well as the reason for the product, are both considered from very early in the product design stage. Concrete, real-life needs must guide product specifications, changes and updates to maximize patient commitment. This strategy reduces the potential risk of having to change the product design later during the development and production process. Receiving feedback from end-users at a regular, milestone-based pace allows product developer to rework their product while there is still time to do so, avoiding usability or design errors. If a product is a complicated to use or non-intuitive, it may very well end up not being used. A strategy to mitigate this risk is to establish a “partner” relationship with advocate patients. Patients decide if the product planned for development is worth using. Collaborating closely with a group of 4 or 5 patients committed to improving healthcare in targeted applications can bring more value than any investment in R&amp;D. Going beyond the consultative role and making this collaboration an active contribution ensures that voice of the patient is considered before the solution hits the market.   Finally, working closely with patients means that their feedback can be integrated and adapted as needed during the product development. The value of this collaboration is to bring a product to market that is both well designed and received by the end users (patients), thus encouraging immediate adoption. Digital health, an asset to meet diversity of needs and enhancing patient experiences However, patient involvement throughout product lifecycle development does not allow for meeting the needs of each individual patient, as of course each patient is unique. There is no such thing as an average patient. Therefore, for the past two decades, pharma bets on digital health to develop tools that collects clinical data outcomes on patients’ vital signs, treatment adherence and quality of life to make medicine more precise.  It is not enough to have healthcare providers prescribe medication and assume that the patient will take it as directed. Likewise, it is not enough for pharma companies to manufacture a medication and simply assume that it will end up in the hands of the patient who needs it and knows instinctively how to take it. In fact, patients face additional clinical and non-clinical challenges when taking their medications. Failing to address these issues makes healthcare services and therapeutics more inaccessible to certain patient populations, further increasing gaps in health equity, quality of life and mortality rates. Providers and pharma companies need to work together to create a comprehensive set of holistic services that go “beyond the pill” - giving patients training, education and support they need to take their medications properly. Through tailored education programs, ePROS, smartphone app push notifications or reminders and digital therapeutics’ medical recommendations based on clinical algorithms, digital health gives providers insights into how a patient is progressing - outside of medical supervision - to adjust treatment plans according to real-life datapoints. By enabling more personalized medicine, digital health benefits both patients and providers. Patients receive significantly more support between consultations. It can help them self-manage their condition, strengthen their self-esteem and reduce their anxiety. Providers can keep a closer eye on patients, which helps prevent disease progression and reduce unnecessary hospitalizations – both of which lower overall healthcare costs.  When developing digital health solutions, patients are an essential resource of knowledge. Working closely with patients and including their feedback are key factors for faster product adoption and engagement. Digital health opens the possibility of a truly participatory and personalized medicine, where patients can access adequate content and track their performance, increasing their levels of autonomy and empowerment.

Enhancing the Patient Experience through Integrated Health Strategies

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Chief Strategy Officer

The management of chronic conditions, such as diabetes, asthma and congestive heart failure, have long required judicious oversight and management from a savvy healthcare provider, along with - in many cases - daily actions on the part of the patient, to execute the evidence and guideline-driven instructions of their healthcare providers to remain in the “safe zone.” Provided the trust behind this arrangement is maintained, there’s the usual cadence of physician office visits - say 3-4 times per year - when the physician-patient team can check in on progress and make any required course corrections. And in more dire situations, or in ones where new variables may be introduced (e.g., the initiation of insulin for a patient who is naive to the drug and to injections as a whole), that frequency of interaction between the patient and provider may increase in order to maintain a safe health trajectory. COVID-19 has turned this paradigm on its head. For months now, patients cannot see their healthcare providers in the usual manner, as offices may have been either closed or imposed restrictions for emergency visits only. In some counties in the US and in some countries globally, this persists today. And that’s not all. COVID-19, apart from its immediate impact on the continuity of care in chronic condition management, has further uncovered underlying and systemic problems in healthcare. As mentioned, the patient-provider cadence of meetings has been interrupted. While telemedicine services can help to address this issue, COVID-19 has further uncovered societal disparities in the basics required for telehealth to even work. Access to reliable high-speed internet, smartphone use and provider practices equipped with telehealth technology are barriers for telehealth in underserved communities. Security and privacy are risks with the rapid introduction to telehealth. When the first wave of tele-consults due to COVID-19 constraints manifested, many shifted to and adopted tools. Adding to the complexity, , some of these tools faced significant challenges as it related to ensuring privacy and security. So while the healthcare community was scrambling to deal with the new impositions of COVID-19, many “holes in the bucket” were discovered. The truth is no one has ever experienced anything like this, and certainly not since the pandemic in the early 20th century. It could take well over a year to develop a vaccine, and even though Dr. Anthony Fauci - the respected and renowned Director of the NIH National Institute of Allergy and Infectious Diseases and arguably, one of the world&#39;s top 5 virus pandemic experts - recently expressed cautious optimism about a vaccine by the end of the year, is that the only solution? Do we sit still in the interim? Enter stage left - Innovation. There is an incredible opportunity for innovation to unlock alternate strategies to help cope with these impositions of COVID-19 on chronic conditions and that too, well beyond our pandemic has subsided. We are beginning to witness this through telehealth and the increase in virtual care. On March 27, 2020, the Coronavirus Aid, Relief and Economic Security (CARES) Act was enacted into law. Amongst other things, the bill provided a further expansion of telehealth services. <a href="https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality" target="_blank">McKinsey recently surveyed consumers</a> and unearthed that 11% of US consumers used telehealth in 2019 versus a whopping 46% who are using telehealth today due to COVID-19 altering healthcare visits and breaking that continuity of care. This can only help so much until it faces the foundational constraints we’ve already mentioned. How do we take this a step further? What else can be done with digital technology and more importantly, the data it generates therein. First, some somber statistics about how dire the risk is for those who suffer from chronic conditions in the midst of COVID-19. According to <a href="https://www.cdc.gov/mmwr/volumes/69/wr/mm6924e2.htm?s_cid=mm6924e2_w" target="_blank">CDC case surveillance in the US</a>, people with chronic conditions are 6 times more likely to be hospitalized and 12 times more likely to die from COVID-19. Diabetes is one of the most common underlying health conditions accounting for 30% of cases. That’s nearly three times the normal incidence of Type 2 diabetes in the US! <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7144611/" target="_blank">What experts now believe</a> is chronic inflammation, immune response impairment, and potential direct pancreatic damage is the association between COVID-19 and diabetes. The <a href="https://www.medscape.com/viewarticle/931470" target="_blank">most recent study published</a> examines specific characteristics before and at the time of hospital admission, which predict worse outcomes among people with diabetes. One of the key conclusions: BMI is a major risk factor. This research determined one in ten people with diabetes hospitalized for COVID-19 die within a week. Thus, chronic conditions must be a part of this conversation and we must move beyond just telemedicine in order to address the problem. The advent of digital health and digital therapeutics - those digital health solutions that generally meet a higher level of rigor associated with evidence, claims, randomized control studies, FDA clearance, cybersecurity certification and clinical workflow integration - has been accelerated by evidence-driven health apps, wearable technology, and advanced sensors. These digital health solutions are already impacting chronic disease management in ways that both traditional care and telemedicine cannot solve alone. Add to that advanced, artificial intelligence and machine learning techniques that can be used to turn patient-generated health data from those who suffer from chronic conditions into behavior patterns which inturn, can aid in the response to their condition amidst this unprecedented pandemic. Digital health solutions can analyze patterns in heart rate, blood pressure, blood glucose, physical activity, weight, sleep, medication adherence, diet, age, gender, you name it. This data can be both self-entered, and also brought-in via a series of technology-enabled (e.g., BLE, NFC, etc.) protocols, to take out the “adoption and engagement friction” associated with manual data entry. In one quick move, digital health improves what we refer to as the four “V’s” of data: Variety, Velocity, Volume, and Veracity. The variety is the data patterns mentioned above. The velocity is near-real time, and the volume therefore is high. With trusted sensor integration, or even integrations with labs and EMRs, the veracity of the data is increased. All of these contribute to perhaps the most important “V” - the fifth one: Value. So what can we do with this data? We can run primary analysis, to address basics like “what’s the pattern for a male vs. a female, younger vs. older, tech-savvy vs. non-tech savvy person, etc. That primary analysis is facilitated by tools such as Tableau, Microsoft Power BI, R and others, where data vectors can be input, cleansed (according to data governance best-practices) and then plotted to inform on “patterns of interest.” These patterns can be a good event (such as a patient remembering to take their medication) or a bad event (such as a low blood sugar value for a diabetic or rapid weight gain for a patient with the onset of CHF). Then, add to this the more advanced statistical pattern recognition techniques of clustering (as an example, K-nearest neighbor (K-NN)), or discriminant functions (as an example, linear discriminant functions) whereby the data isn’t just answering “what” event happened, but more importantly, “why” it happened. Once a pattern is discovered, probabilistic and predictive models can then be used to understand “when” such an event may occur again. There are predictive models - the likes of Gaussian, Bayesian, Markov and others - that can be used to predict the trajectory of a patient. And finally, these data then fuel adaptive models, which apply machine learning algorithms to “fine-tune” and adapt the model to track, trace and predict a patient’s pathway based on the data they are entering. The output of such analysis can inform providers to then apply their clinical training to guide the patient to the best therapy pathway. Without the data and advanced algorithms, the provider will have little to go on, but their ability to optimize the treatment pathway for the patient is illuminated by data and analytics. Welldoc has used such techniques to predict the onset of hypoglycemia, develop models that isolate feature usage within the digital health solution that are predictive of a successful pathway, and continued persistence of engagement to ensure the patient remains in the “safe zone.” All of this while not being able to physically or virtually “see” their healthcare provider. What we learned through our research is early identification of individuals at risk of either succeeding or failing with a specific therapeutic pathway. Leveraging data and advanced analytics associated with digital health can therefore increase the efficacy of telehealth services to be more patient and condition-specific. We can apply these methods to COVID-19 too and learn clues from patients who are suffering to better inform our response. What are good and bad symptoms that impact the onset or recovery? It’s important to note that this can be very individualistic. Hypothetically, we may discover that an unrelated medication mitigates progression for many patients, but the taking of certain actions can have a completely different effect for two different individuals.  The bottom line is digital health solutions offer hope and can help us address this conundrum when a doctor’s office is empty and patients can’t leave their homes. Remote capture of real-time data coupled with predictive analytics are key during this pandemic and beyond. The capability exists to remotely monitor critical health conditions, predict future outcomes and utilize data analytics to help drive the course of patient actions to a more healthy future.

Role of AI and Machine Learning in Chronic Disease Management During COVID-19

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