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Executive Vice President and Chief Impact Officer

In response to the COVID-19 pandemic, our team will be interviewing experts from across the ecosystem to bring the HLTH community timely facts and updates. About Nimesh Jhaveri:  Nimesh is president of Health Mart Pharmacy and senior vice president, McKesson Pharmaceutical Solutions and Services. In his role, Nimesh is responsible to provide visionary and strategic leadership that ensures growth and stability for the 5,000+ Health Mart Independent Pharmacy franchise. He oversees Health Mart field operations, support operations, strategy, and business development. Nimesh joined McKesson in 2018. Previously, Nimesh led healthcare services for the Walgreen Co., where he spent 29 years in various leadership roles leading business development for pharmacy practice design, automation and technology, pharmacy operations, human resources and corporate operations. During this time, he drove the creation of market leading technology and design, earning numerous patents granted by the United States Patent and Trademark Office.

COVID-19 Discussion with Nimesh Jhaveri, MBA, R.Ph.

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In response to the COVID-19 pandemic, our team will be interviewing experts from across the ecosystem to bring the HLTH community timely facts and updates. HLTH Team: Can you tell us a little bit about your past experience working at the CDC? David Van Sickle: Between 2004 and 2006, I was an Epidemic Intelligence Service officer at the Centers for Disease Control and Prevention in Atlanta. As part of the Air Pollution and Respiratory Health Branch, I provided epidemiological support to the National Asthma Control Program, and investigated the health effects of a variety of environmental exposures, including chlorine gas in South Carolina, carbon monoxide in Florida, and ambient ozone among student athletes in Georgia. I also helped establish emergency illness and injury surveillance in coastal Mississippi and New Orleans after Hurricanes Katrina and Rita.  HLTH Team: How do you feel the CDC’s response has been so far to COVID19? What can we expect from them moving forward into later stages of the pandemic’s progression? David Van Sickle: I hope and expect a lot more public-facing leadership and activity from the agency. It has been weeks since CDC has held a media briefing. As others have noted, it is past time for them to assume leadership and command of the situation, prepare a national strategy, and mobilize every necessary resource required to slow and then turn things around.  Part of the problem is that we’re demanding a return on investment we have failed to make in public health. Year after year, the CDC has had to make do with less. It is hard to overstate how valuable those investments -- at federal, state and local levels -- could be today. Compared to the U.S., the experience of coronavirus in countries with strong and prepared public health infrastructure could not be more different. There are no shortcuts, unfortunately.  HLTH Team: What is unique about COVID19 from a respiratory disease perspective? What makes it particularly dangerous? David Van Sickle: Across the world, we’ve seen coronavirus create a significant unmet need for life support ventilators. During my time at CDC, I responded to a train derailment in South Carolina that caused the release of approximately 60 tons of chlorine gas, sent hundreds to the hospital, and demonstrated the potential for even local disasters to overwhelm healthcare delivery. At the time, and in response to concerns stemming from September 11th, the Department of Homeland Security developed a set of National Planning Scenarios, published in 2006.  This document highlighted a number of catastrophes that would require access to many more ventilators than would otherwise be available. The scenarios included chemical terrorism, such as the deliberate release of chlorine gas from a railcar in an urban area, and a return of pandemic influenza. We’re now confronting circumstances clearly anticipated by this work and finding ourselves dangerously unprepared.  HLTH Team: How has digital health stepped up to the plate in slowing the spread and helping to triage patients? David Van Sickle: We’ve seen digital health companies respond with a range of solutions, from diagnosis to treatment. A wide variety of tools are available to help people better understand coronavirus and COVID-19 screen themselves for the disease and locate where to get tested. Telehealth platforms have played a central role in helping people to consult remotely without having to visit a clinic, which has helped to minimize unnecessary impact on health systems.  Companies such as Big Health and Omada have worked quickly to make their digital health tools available to people affected by the pandemic, with the goal of minimizing mental health consequences. At the same time, CMS has implemented new guidance to clarify and encourage the adoption and reimbursement of digital health and remote monitoring. At Propeller, we’ve been collaborating with health system partners to help them adopt digital health for asthma and COPD. With clinics focused on COVID cases, and many in-person appointments cancelled, a digital health tool like Propeller can help them provide preventive care without a clinic visit, freeing up resources to meet the need of people with asthma and COPD who need immediate attention and the emerging demands of COVID patients.  HLTH Team: What makes those suffering from chronic disease at high risk and how can digital health help protect that particular population? David Van Sickle: The clinical epidemiological data suggest that individuals with preexisting conditions tend to do worse when infected with coronavirus. This includes people with chronic lung disease such as asthma and COPD. Current guidance from the American Thoracic Society and the AAAAI, as well as GINA, recommends that people with respiratory disease continue to take their daily preventive medication during the COVID-19 pandemic.  Patients who adhere to their medications, and whose symptoms are well managed, may have fewer concerns about symptoms of chronic lung disease being associated with COVID-19. Patients with well-managed symptoms are also less likely to seek acute respiratory care at healthcare facilities and emergency departments, which decreases the risk of incidental exposure to SARS-CoV-2 and allows healthcare providers to focus attention on patients with other critical needs.  This is where digital health comes in. Patients who use a digital health platform to manage their asthma and COPD are proven to adhere to their medication regimen more closely, and experience fewer serious symptoms.  The good news is that since the COVID-19 outbreak began to ramp up in January, our data shows that people with asthma and COPD have been 14.5 percent more adherent to their medication, with the steepest increases occurring in the last two weeks of March. This indicates that patients are taking expert recommendations on adherence seriously and prioritizing their preventative health with the help of a digital health tool.  HLTH Team: How has state and federal governments best utilized tech during this pandemic? Where do you see tech becoming an even more important piece of the solution moving into the next several months? David Van Sickle: We think the use of technology in the ongoing care of chronic disease will surge due to COVID-19. With federal reimbursement now in place to support remote patient monitoring and management, we can expect routine visits -- designed to assess patient status and make necessary adjustments to treatment -- to move online.  Because digital health tools can monitor patient well-being at a distance, it will be easy for providers to make evidence-based decisions on patient care by looking at digitally collected data. With these changes, it should be possible to lead more people to minimally-burdensome treatments that truly control symptoms and help them participate fully in the activities they choose.  HLTH Team: Lastly, what do you feel have been the top 3 lessons learned so far in battling this pandemic?  David Van Sickle: A global community of scientists and doctors came together in a way I’ve never seen before. With the help of technology, the community immediately began collaborating, learning and improving day after day. We quickly had diagnostic tests, candidate therapies, and potential vaccines under study. Thankfully, coronavirus has neither the speed nor the agility to keep up. But the approach of the clinical and scientific community, which united to face the virus and share and apply emerging knowledge and practices, has not been adopted as consistently by governments. Instead we’ve seen slow and variable responses, muddied by disbelief and denial, resulting in avoidable disasters. At the moment, we have learned enough from the global experience to assemble a national strategy and effective counter-measures. What we need now is coordinated leadership to pull this together and put it to work. About David Van Sickle: David Van Sickle is the co-founder and CEO of Propeller Health, a leading digital health company dedicated to the management of chronic respiratory disease. He founded Propeller Health in 2010 after observing how digital health tools could improve the experience of chronic disease and give patients and their providers new insights into their disease. David received his PhD in medical anthropology from the University of Arizona in 2004 and went on to complete his dissertation research on the rising prevalence of asthma and allergy in India, a topic he previously studied among Native Americans in Alaska, Arizona and New Mexico. From 2004 to 2006, he served as an Epidemic Intelligence Service officer at the Centers for Disease Control and Prevention in Atlanta, assigned to the Air Pollution and Respiratory Health Branch. During that time, he provided epidemiological support to the National Asthma Control Program and investigated the health effects of a variety of environmental exposures. Between 2006 and 2009, David was a Robert Wood Johnson Foundation Health and Society Scholar at the University of Wisconsin School of Medicine and Public Health. David specializes in asthma, chronic respiratory disease, medical device development, health data and disease surveillance.

COVID-19 Updates with David Van Sickle

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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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Head of New Ventures

<a href="https://chronicdisease.org/wp-content/uploads/2022/04/FS_ChronicDiseaseCommentary2022FINAL.pdf" target="_blank">Nearly 60%</a> of Americans live with a chronic disease, such as heart disease, cancer and diabetes, that impacts their quality of life and requires active daily management. While patients have historically relied on their physicians to help them manage long-term conditions, this has become more burdensome for providers due to the complexities of comorbidities, growing life expectancies and larger patient panels.  In addition to the burden placed on providers, chronic disease is a significant, and largely preventable cost burden, especially for older patients with multiple chronic conditions. More than half (53%) of <a href="https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/chronic-conditions/ccdashboard" target="_blank">Medicare&amp;#039;s annual spend</a> can be attributed to the 18% of the Medicare population with six or more chronic diseases. When you layer a nationwide provider shortage and the ongoing shift of costs from payers to providers on top of them, it’s clear chronic care management (CCM) is overdue for innovation. The need for comprehensive care models  Traditional care models have always attempted to make patients active and accountable participants in their own wellness journeys, but results have been mixed.  For example, diabetes management requires extensive education and behavioral interventions – including medication, nutrition, exercise and self care. Maintaining these habits over time can be challenging, even for the most motivated patients. “Almost half of patients with diabetes are coping with some form of chronic depression due to the complexity and 24/7 nature of the condition, so mental health care is a vital element of the care program,” says <a href="https://www.linkedin.com/in/davidweingard" target="_blank">David Weingard</a>, Chief Strategy Officer and founding team member of a stealth company incubated at Redesign Health that empowers endocrinology practices to deliver comprehensive, value-based diabetes care. The most effective CCM programs must holistically address the social and environmental factors that impact patients’ health, through both primary and specialty care. But many provider organizations lack the time and administrative resources to stand up such a comprehensive and billable CCM program.  Why healthcare startups are poised to improve CCM for all A new type of patient-centered, wraparound care offers a solution to these challenges. In this model, providers work alongside patients, using tech-enabled tools across multiple specialties and conditions.  Third-party innovators, like Redesign Health’s Operating Companies, are uniquely positioned to develop a comprehensive approach to CCM that helps patients stay as healthy as possible and reduces the burden on physicians. 1. Innovation offers a clear path forward. The rise in telehealth utilization and the maturation of communication technologies open the door to infuse innovation within CCM journeys. “Furthermore, <a href="https://www.cms.gov/medicare/medicare-fee-for-service-payment/hospitaloutpatientpps/downloads/payment-chronic-care-management-services-faqs.pdf" target="_blank">the CCM cohort of CPT codes</a> that are available since 2014 from CMS have provided opportunities for start-up companies to structure a support network for patients, coordinate care across the healthcare ecosystem and communicate effectively across the network so all caregivers are engaged and set to optimize care for the patient,” says <a href="https://www.linkedin.com/in/scottwdischmph" target="_blank">Scott W. Disch</a>, a Venture Advisor at Redesign Health. 2. Health plans need strong partners to deliver deeper CCM insights to their members. Health plans and employers are improving CCM by expanding reimbursement models and offering patient-facing programs designed to work across disease states. But health plans can’t take a deep dive into a disease state or identify specific behavior adjustments to improve their member’s overall health, because of this focus on breadth over depth. Oftentimes, these call centers are staffed by coaches or clinicians who are primarily trained to triage immediate needs for high volumes of members.  “A partnership with a healthcare startup can supply the domain expertise at scale to ‘go deep’ within a disease state,” Weingard says. “The complementary value of the startup world—coupled with the health plan’s real-world expertise and access to members—can provide significant opportunities for scaled and improved patient care.” 3. The transition to value-based care will require proven use cases. A comprehensive CCM solution enhances outcomes in the current fee-for-service environment. It also provides proof points which can be used to build case studies which support a seamless transition toward value-based care models for all stakeholders. Our approach to building CCM-focused operating companiesWhile some startups provide point solutions for CCM with one or two direct care interventions, this approach is too limited. Delivering true wraparound care is critical to improving outcomes and increasing billable provider revenue. To this end, we’ve already launched eight Operating Companies that provide wraparound care across multiple specialties —heart disease, cancer, behavioral health —and we have nearly a dozen more in our pipeline. Our operating companies strive to enhance CCM across the board by:<ul><li>Improving the patient experience with real-time medication adjustments, care coordination and supportive touch points between appointments</li><li>Enhancing patient adherence to their care plan, driving measurement-based care decisions and encouraging patients to use less costly sites of care</li><li>Engaging all of a patient’s caregivers to reduce the chances of unneeded tests, delays in care or poorly aligned treatment</li><li>Reducing provider workload and enabling them to practice at the top of their licenses</li><li>Making it easier for providers to infuse social services into the CCM process</li><li>Integrating automation to reduce documentation shortfalls, improve compliance and engage a wider patient base</li></ul> “Combining a CCM program with direct care interventions helps patients and caregivers connect with their provider network in a meaningful way, while offering providers an ‘air-traffic controller’ of healthcare to hotspot issues before they arise, engage in and improve quality care outcomes, and be an ombudsman for the patient as they navigate decisions with their chronic illness,” Disch says. Final thoughts When providers must rely on office visits alone to manage patients’ chronic conditions, it creates insurmountable burdens for both providers and their patients. Wraparound care fills in the gaps, giving primary care providers and specialists the people, processes and technology they need to improve their patients’ outcomes across multiple disease states.

Wraparound Care: The Next Frontier in Chronic Care Management

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