This is the transcript for episode 397 of the Community Broadband Bits podcast. In this episode, Christopher speaks with Danika Tynes from Georgia Tech Research Institute about different ways to get telehealth service in remote places. Listen to the episode, or read the transcript below.
Danika Tynes: Put the need first. Let the technology follow.
Lisa Gonzalez: Welcome to episode 397 of the Community Broadband Bits podcast from the Institute for Local Self Reliance. I'm Lisa Gonzalez. As more people become better connected with broadband, especially in rural areas where hospitals are few and far between, the healthcare industry is finding new ways to use Telehealth applications. This week Christopher talks with Danika Tynes from the Georgia Tech Research Institute about what's working in Telehealth and ways to move forward. Danika talks about policy, funding and ways to get the community involved in order to improve the likelihood of success for new Telehealth applications. Now here's Christopher talking with Danika Tynes from the Georgia Tech Research Institute.
Christopher Mitchell: Welcome to another episode of the Community Broadband Bits podcast. I'm Christopher Mitchell at the Institute for Local Self Reliance, normally in Minneapolis, but today in Raleigh where it's much warmer than it normally is in Minneapolis this time of year, I'm speaking with Danika Tynes, the senior research associate of the Georgia Tech Research Institute. Welcome to the show.
Danika Tynes: Thank you, Christopher. Thank you for having me.
Christopher Mitchell: It's great to have you here. I'm still in North Carolina. We're here at the NC State where the Institute on emerging issues is having a conference on part of the Reconnect series in which we're talking about today, technological opportunity. Your specialty is Telehealth and I'm very excited to dive into this to talk about what's happening today, where we're going. And your panel, which is going to be about what's possible in the best future that we could have in which we all have great access and everyone is connected. I think it's going to be a great panel and I recommend people go back and stream it once they listen to this interview, but I'd like to first ask you to just tell me about the Georgia Tech Research Institute please.
Danika Tynes: GTRI, Georgia Tech Research Institute is an arm of Georgia Institute of Technology, so it is focused on how to innovate in different organizations. They do a lot of Department of Defense work of course. Right now one of the projects that I'm working on is to modernize the Medicaid management information system and so we're building the systems platform and we're taking it into the Cloud. And what that does, it allows for more modularity, better competition amongst vendors as well as more scalability. And so when we take a solutions into the Cloud, we're also reducing the cost to taxpayers. And so we're bringing innovation to how we do common things like support our Medicaid and Medicare populations.
Christopher Mitchell: Wonderful. And I just have to say probably some of the most important stuff. One of the things that we can talk about that I suspect is true is that even if we lived in a world right now where there was really widespread broadband access to everyone and everyone could afford it, we would still be limited by the processes that are being updated in your work.
Danika Tynes: Yeah, absolutely. 100%.
Christopher Mitchell: And so I think it's one of the things for those of us that really focus on broadband expansion, we want to also have a sense of reality, which is that the things that are limiting Telehealth aren't just broadband capacity, but it is one of the factors. So let me start by asking you, what is working in Telehealth today? not where are we going to be soon, but what's been going on, in 2019 what was working well in Telehealth?
Danika Tynes: So I can probably couch the answer to that in an anecdote of a project that I did in Mississippi. I was working with the North Mississippi health Services. North Mississippi Health Services has a hospital systems centralized in Tupelo, Mississippi and then 23 other clinics that are spread across rural Northern Mississippi. And so this hub and spoke model made them a really great candidate for a Telehealth solution. Because they had the infrastructure as well as the specialists needed in the urban center in Tupelo that would benefit the rural population. Our first case, our first patient who came through this program, she was a diabetic patient. She lived about an hour and a half from Tupelo. She had two jobs, a morning job, a evening job, and so she had missed her last five diabetes appointments with a specialist who was in Tupelo. She also had trouble securing transportation.
Danika Tynes: So here we have, now we've implemented Telehealth and in her local clinic with her provider, with her nurse, whom she knows very well, she's able to now take a Telehealth visit and close the care gap and get now a care plan to help manage her diabetes. And the added silver lining that we got out of that was the benefit of having the nurse and her primary care physician on the other end of that synchronous visits to hear what the specialist was actually offering. So it was more of an integrated care model. So now they could reinforce the messaging of the diabetes specialist. So that was our first patient. And I loved, I felt so close to being able to make an impact in the world when she was the first one to come through.
Danika Tynes: But there's a few things that made that possible. Number one is there was policy in place. So Mississippi determined and their legislature maybe five years ago, that private payers had to reimburse Telehealth services at the same level as face to face. That was number one. That is not a federally mandated thing and it is encouraged by CMS. CMS has models in place for Telehealth reimbursement, but it's up to the states to adopt their own legislation in that regard and allocate those funds. That was the first thing that was in place.
Christopher Mitchell: And this is a wonderful, we live in a world of abbreviations and telecom, but what is CMS?
Danika Tynes: Centers for Medicaid and Medicare Services. And so we have a huge population that benefits from Medicaid and Medicare services and many of those populations are found in rural areas or even urban areas. And to that extent is if we are offering a technological service that we don't want to edge out those who are benefiting from a federal health care plan.
Christopher Mitchell: Right. And then just for people who aren't as familiar, Medicaid, a lot of children get coverage through Medicaid. A lot of people who are disabled, it's a vulnerable population typically. And so these are the people who often have the hardest trouble getting to Tupelo or another major population center where you may have the specialists.
Danika Tynes: Right. And frankly, I don't know what the person of Mississippians is leveraging those federal programs, but I think despite where you live, whether it's Jackson or outside of Jackson, I think that it's probably a high percentage. And so you don't want to further marginalize those who participate in that program by offering services that they can't benefit from.
Christopher Mitchell: Right now you were saying, number one was policy that made this happen. What's the second thing?
Danika Tynes: Funding. So North Mississippi Health Services, they obtained a large grant for their startup costs. They also had the hospital that was able to pick up some of the funds and allocate the resources like the IT department needed to shift over their resources to help make this happen. So I think having financial resources upfront is really huge. One of the first things that we did to identify the feasibility of Telehealth, because it's not feasible everywhere. And I'll come back around to of my recommendation for when to adopt Telehealth and when not to.
Christopher Mitchell: Okay.
Danika Tynes: Because there are cases of when not to. We get really excited about Telehealth as a silver bullet. But funding was really important. One of the things that we did before we implemented all of the sites as we kicked the tires on their broadband. Was the broadband fast enough? Could it detract from the experience of Telehealth? If you're having now a same time, real visit, over video with your physician and you get cut off, that's going to take away from your appreciation of the experience. It may make you distrust technology and now you're moving in the wrong direction of where you want to go.
Danika Tynes: So I think having the proper funding in place to have all of those fundamental things, the technology, we had to buy carts for to provide Telehealth. So we would take the carts into the provider area, so into the clinics or into the skilled nursing facilities, and we would post them there. And then we have the peripheral. So you could hear the heartbeat, you could listen into the mouth, into the ears. And the one other responses from the physicians was, "Wow, these peripherals offer such an amazing option for me that gives me better results than my naked eye." Because they could take pictures and so forth.
Christopher Mitchell: And record it too for... Yeah.
Danika Tynes: So that's exactly right. The other thing is that they had the infrastructure in place. So the network already had electronic health records implemented and so they were able to interface these two technologies. I found this out a long time ago working with University of Texas Medical Branch. They tried to implement Telehealth without having their EHR, their health records in place. Well that's really disruptive to the visits. So you don't want to not look someone in the eye, a patient in the eye because you're here talking about their health. So you want to be present with them. Well without an electronic health record, you have to look down and flip through a chart. And so having a setup where the physician can actually look at the patient and glance over to the side to look at the chart is really helpful. So that maintains that connection since we are now talking through a TV essentially.
Christopher Mitchell: Right.
Danika Tynes: I think, as well, another thing that was really important to have in place and to make that successful was the training. And in the conference today we talk about workforce readiness and inclusion and literacy. And I think that was really, really key in making that rollout successful, is that along the way we engaged all of the appropriate stakeholder communities, the providers, the patients, those in the community. We actually put out articles in the newspapers so people could start talking about it. And some of the providers thought, "Hey, are you going to take away our jobs?"
Christopher Mitchell: Right. Yeah, I can imagine that.
Danika Tynes: Is this why you're taking away our jobs? And so it was really interesting, some of their perceptions we heard back and advancing the conversation and in opening up the communications. And so it was, "No, actually we're here to help you do your job better. And help you keep your community healthy." We had IT departments that were just going, "This is just one more fancy thing that they're throwing on us." Didn't get it.
Christopher Mitchell: Right. They're not going to call you when something breaks.
Danika Tynes: That's right. Or and now you have to change all the way that you do billing. You have to update that into the system. You have to create a code because now this is a Telehealth visit. So you have all of these considerations of who are the stakeholders who are impacted, and then of course the patients. "Well, I don't even like going to the doctor in the first place and now I have to use this technology thing then I'm not comfortable with." And indeed we did do surveys subsequent to the rollout to understand the level of satisfaction or frustration of using Telehealth and the satisfaction level was just as high, if not higher, as in person visits. I think those are probably the key things.
Danika Tynes: Probably one last thing I would say is top-down reinforcement. I think it's very important. We heard some great speakers today talking about getting the role allocated to have the conversation around digital inclusion, but not necessarily the funding. And so when we see leadership, not only stand behind the idea, but stand behind it with funding or reinforcement or talking about it, that really helps things to gel and take hold.
Christopher Mitchell: There's so many things I want to react to because it's fascinating. But the first one is, is that, I don't know if people appreciate this, my mind is always blown at. There's really two major things that we can do as far as I understand, and this is an oversimplification for someone who's not working directly in healthcare policy, but if there's two things that we could do to try to drive our costs, longterm cost of healthcare down, it's better managing people with diabetes and better managing people that have longterm cognitive decline. And so this is a big deal. If you can make sure that people are able to go to their doctor's appointments and more easily and take it more seriously and have followup. It's a major deal for the future of healthcare in America.
Danika Tynes: Yeah, absolutely. 100%.
Christopher Mitchell: So now the interesting thing to me is I feel for people who are trying to figure out how to get connections into the home, there's this vision of, "Okay, what can we do for Telehealth in the home?" And I've talked with some people about that in the past, but I'm just curious about your reaction because you smiled as soon as I started saying that. Is the better solution right now basically focusing on these centers that are within the community, making sure you have a very high quality sort of managed experience there. And that's the goal right now to get to?
Danika Tynes: I could say a proper generalization just across the board in healthcare, is that people always do better at home. And we have a huge chronic disease challenge, not just here, but everywhere in the world. Chronic diseases continue to climb. And one of the most promising ways to address that challenge because we have limited physician and caregiver resources to take care of patients every day in the hospital. One of the plausible viable solutions for that is remote monitoring. And the thing about remote monitoring goes back again to a work force literacy is that it necessitates data. And people who can absorb data, understand data, understand how to create trigger mechanisms, if the remote monitoring data that's coming back from a patient is outside of what one would deem normal, workflows that then what happens if there's some sort of alert to the physician. Now what do we do from there?
Danika Tynes: But it's a really viable option for managing chronic disease. In fact in the session later I'll introduce a couple of data points around how Telehealth has demonstrated to reduce chronic care patient visits to the ER, which is a huge cost to taxpayers. So I think you're right on by being interested in that conversation because it's one of the most viable applications of Telehealth where we could see outcome impacts.
Christopher Mitchell: And when you say the data, we're not necessarily talking about invasive things like things that you'd have maybe an implant for. It might just be your weight.
Danika Tynes: It might be a weight, it could be a blood pressure. But then off of that data for providers to really... And we're talking about what's happening now, but where do you take that in the future? And we always are trying to look at, how do we make this scalable? Once you have your infrastructure in place, what do you do then? How do you create more information with few resources? And data is one way to do it. So if I'm a physician and I have remote monitoring capabilities for, I don't know, 10,000 diabetes patients, I may want to look at the aggregate of all of that data and see if there's a way that I can help you better, help you more, advance and shift the needle on outcomes. And so that's when data becomes really important. But our ability to absorb data and interpret data also needs to heighten simultaneously.
Christopher Mitchell: I can imagine a situation which you would say, "We've found that you have this trend and in 90% of people that have this trend, this thing is coming down the line and let's try to address it earlier."
Danika Tynes: That's right. Exactly. So we find ourselves in much more proactive stance when we can understand the data.
Christopher Mitchell: So you said that you wanted to come back to where Telehealth might not be the better solution. I want to make sure we talk about that.
Danika Tynes: Yeah, so I feel what we always want to remember and why we choose the field of health to participate in is because we want our population to be well, all of our populations to be well. And for that, I think we always need to start with the need. Every community is faced with different cultures, different needs, different barriers. I think you have some legislative barriers here in North Carolina for Telehealth that might not be the same barrier that you have in a Mississippi where the health burden is a lot larger. So everybody has different barriers. And I think it's making sure that we stay connected to what the need is. So for example, let's say a community is faced with an overwhelming burden of obesity and we see how that translates into chronic disease. That's one of the social determinants there. So maybe instead of saying, "Telehealth can help, it fixes everything." Well maybe the local high school can open up the gym after hours and share it with the community that may not have one. Maybe we start a community health walk and everybody goes outside at 5:00...
Christopher Mitchell: Right.
Danika Tynes: ... And does it. So there are some human things that we can do without technology that can help address the need rather than trying to throw technology at it. So I would just always say put the need first, let the technology follow. As far as I'm concerned, technology is zeros and ones. That's it. We can build anything. Anything you want built we can build.
Christopher Mitchell: It sounds like someone from the Georgia Institute of Technology.
Danika Tynes: Yes. Yes. Because lots of research that we do... I think I just read an internal article the other day where we're offering to replace the power grid with batteries. you can build anything. So it's really get connected with your community, get connected with your social determinants, get connected with what can actually move the needle and create change in your health outcomes and then decide what you want to apply to it.
Christopher Mitchell: This is going to be a weird, seems like a weird tangent, but it's going to come back around.
Danika Tynes: Gotcha.
Christopher Mitchell: Last week was National Girls and Women in Sports week. A lot of states celebrate a specific day and for the past 12 years or so I've done photography for the Minnesota version of that. Because I moonlight as a photographer and do a lot of sports photography, so through them I met this group. There was a group being honored for doing granny basketball in which I think is women who are over 50, many of whom did not have opportunities to play because we had no Title IX when they were growing up. And so they have formed these leagues in which they play with their own set of rules that's appropriate for their age and mobility and just to have fun.
Christopher Mitchell: And what you were saying about Telehealth, just the costs of as establishing Granny Basketball Leagues are such that if you prevent one person out of probably 20 teams from developing a health problem that has paid for it. And yet these Granny Basketball Leagues are looking for grants sometimes to be able to get court time and things like that. And so I think it's really important to think about these things about being creative and not just saying Telehealth, Telehealth, Telehealth, but to recognize that we need to figure out how to make people more active in a lot of ways.
Danika Tynes: Right. Yeah. We don't want it to become this buzz thing. And like I said, the more times we try to apply a technology that isn't appropriate for its application, the more distrust we have in technology. And that's opposite the direction we want to go.
Christopher Mitchell: Right. Yes. And I just... One of the things that we talk about in health is that the cost of building broadband networks roughly in rural North Carolina, I think you could assume it's on the order of, I don't know, $2,500, $5,000 depending on a onetime cost to connect a home with a fiber optic network. And it sounds like a lot of money. In the healthcare field, it's not a lot of money. And so I just feel it's useful to break these frames of reference. We get caught up thinking about what is a lot of money in healthcare, millions of dollars is a lot of money per person. So anyway, I appreciate the context of how to think about these things. So I feel in telemedicine, a lot of us, I certainly do immediately think, rural solution, but I'm guessing there's urban implications for telemedicine as well. And I'm curious what are we overlooking there?
Danika Tynes: Hugely. So where Telehealth has evolved to is it was an access gap closure tool initially. And now I read articles literally every day of new applications of Telehealth. This morning an article came out about applying Telehealth to reduce physician burnout. Go figure. So now it's not just about closing physical access gaps to care like rural urban. Now it's about education. It's about a synchronous. So you have synchronous, same time, real time Telehealth and asynchronous, which is, it could be slightly disjointed...
Christopher Mitchell: Email for instance.
Danika Tynes: That's right.
Christopher Mitchell: I have a non emergency question for my doctor.
Danika Tynes: Exactly. So non synchronous. So both of those types are being fully leveraged in so many different and innovative ways that the application of Telehealth is not just for the rural community. Where I think you'll see a huge impact though is in the rural community. Similar to the first anecdote I offered up about Mississippi and the diabetic patient who couldn't access her care and now she can. And so it's so easy to see the impact of that. But then as you start expanding, "Well it's basically televite." It's just two way communication between individuals and so we can solve all the problems of the world that way. I don't think that rural health is now the driver for Telehealth, but it is certainly a tried and true and viable application for it.
Christopher Mitchell: Yeah. And when you put it like that, it's this situation or we used to... Egames, E this, E that and then over time it's not E anymore, it's just what is. And in 10 years there's not going to be Telehealth, there will be health.
Danika Tynes: That's exactly right. And I offer up Telehealth, it's really an adjunct to health care. And when it works well is when it becomes part of how we do business. It's not just this side appendage that's a fun project over here, but it's just part of the workflow. It's what we do. And eventually it will look like that.
Christopher Mitchell: So let me ask you, is there anything you want to wrap up with?
Danika Tynes: Yeah, absolutely. So just a quick story about how I've used Telehealth is that there is an app called Doc on Demand. I was driving through rural Mississippi and I was feeling a cold coming on. And so I pulled over to the side of the road and I went on line, I logged into the app and I had an immediate appointment available. It costs me $40, I was out of pocket, but I was in the middle of Mississippi. And so what else could I do? And so they said, "Okay, we can give you a prescription for this medication. Where's your nearest pharmacy?" So I let them know the address of the nearest pharmacy I just pulled up to one.
Christopher Mitchell: Right.
Danika Tynes: And so they called in my prescription right then and I was able to go and then I was able to go about my day working. And so it was a real satisfier for how I went about my day. I wasn't standing on lines, I wasn't waiting in a doctor's office.
Christopher Mitchell: Searching Yelp for the closet doctor.
Danika Tynes: Exactly, exactly. I wasn't trying to find the closest pharmacy. They told me where I was and what I needed to do. And so under circumstances like that, I think that can save us so much time, save families so much time going to doctor's offices, taking their kids out of school. I think as we start to get more comfortable with the technology, we're going to actually see that becoming our new reality.
Christopher Mitchell: Great. Thank you so much.
Danika Tynes: Thank you.
Lisa Gonzalez: That was Christopher talking with Danika Tynes from the Georgia Tech Research Institute. They were discussing Telehealth and how it's making healthcare more accessible for more communities. We have transcripts for this and other podcasts available muninetworks.org/broadbandbits. Email us firstname.lastname@example.org with your ideas for the show. Follow Chris on Twitter. His handle is @communitynets. Follow muninetworks.org stories on Twitter. The handle is @muninetworks. Subscribe to this podcast and the other podcast from ILSR, Building Local Power and the Local Energy Rules podcast. You can access them anywhere you get your podcasts. You can catch the latest important research from all of our initiatives. If you subscribe to our monthly newsletter @ilsr.org. While you're there, please take a moment to donate. Your support in any amount helps keep us going. Thank you to Arne Huseby for the song, Warm Duck Shuffle licensed through Creative Commons. This was episode 397 of the Community Broadband Bits podcast. Thanks for listening.