Behavioral health is already an under-realized field in healthcare. Treatments for behavioral healthcare aren’t as profitable as other sectors in healthcare that have more procedure-oriented care. Because healthcare workers tend to congregate mostly in urban areas, there’s also an apparent shortage of behavioral healthcare professionals in rural areas. These factors among many others contribute to a less-than-substantial standard for behavioral health. Adversely, these effects are amplified in rural areas.
Major Challenges Facing Rural Behavioral Health
In a recent article in Scientific American, Consuelos highlights the many barriers rural communities face in behavioral health as well as healthcare overall. Our head of marketing, Kurt Schiller, and Dr. Consuelos will exchange thoughts and ideas surrounding the situation and how telehealth and interoperability could play a part in closing the gap.
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The podcast will focus on these major questions:
- What variety of factors cause a weakened behavioral health system in rural America?
- Can elevated patient-engagement improve behavioral health?
- What is the implication of telehealth during the COVID pandemic?
- What are the benefits of delivering behavioral healthcare through telehealth?
- What role do major EHRs and interoperability play in healthcare accessibility?
In this episode of Product Hacker, we are kicking off a new segment called Engineering Health where we’ll focus on the intersection of healthcare and technology. Our guest is Dr. Michael J. Consuelos, Principle at MJC solutions, has co-hosted the Pivoting Around A Pandemic series with co-host Jenny Blake of the Pivot Method, and is a pandemic expert. He’s also a healthcare executive, pediatrician, and army veteran. This week, we’ll be discussing the behavioral health gap facing rural communities in America.
Kurt Schiller [00:00:02]: Hello and welcome to Product Hacker brought to you by Arcweb Technologies. I’m your host, Kurt Schiller. This week we’re debuting engineering healthcare, a new feature where we’ll be exploring the intersection of healthcare and technology. This week, we’re taking a deep dive into the challenges of behavioral healthcare delivery and an exploration of how technology might be able to help.
Kurt Schiller [00:00:21]: Stay tuned for future episodes about more aspects of the healthcare experience from clinical data and interoperability to transportation needs and social determinants. Thanks again for listening and enjoy engineering healthcare.
Kurt Schiller [00:00:32]: Access to behavioral health treatment is one of the biggest challenges in healthcare today, with a tangled and often conflicting network of coverage gaps. Lack of providers and cultural norms buildings to nothing short of a crisis. It’s an even bigger challenge in rural communities, where the closure of rural hospitals and added difficulties of transportation and socioeconomic factors is beginning to have far-reaching consequences for things like population health. To explore this topic, we’re joined today by Dr. Michael J. Consuelos, a principal at the healthcare consulting and advisory firm MJC Solutions, as well as a pediatrician and healthcare executive. He’s also the author of a new article in Scientific American, “Rural Communities have a Behavioral Health Treatment Problem. Dr. Consuelos, welcome to the show.
Dr. Michael Consuelos [00:01:16]: Hi, Kurt. How are you?
Kurt Schiller [00:01:17]: I’m doing very well. You know, I think everyone right now is living in interesting times. It’s especially interesting to be talking about behavioral health and, you know, telehealth solutions at a time when suddenly it’s on everyone’s minds.
Dr. Michael Consuelos [00:01:31]: Yeah, I know. Thank you. And then just for your audience. So I wrote this article that you mentioned in Scientific American a couple of weeks into COVID, but not really because of the way they do the work. You know, these are sort of approved and edited and then published, you know, three to four weeks later. So had I written that article today, I probably would’ve said many of the same things but would have really had a different spin. And I think just right off the bat, the social isolation that you just mentioned, that being in that space where you’re not with other people, is going to have a significant impact on behavioral health across the country and specifically in rural areas. Now, that being said, we’re seeing in the news quite a bit were more rural areas aren’t being impacted as greatly as urban areas with COVID19. So maybe there is a little bit more social gathering flexibility. States are opening up a little bit more, but there’s still that greater pressure that you’ll see due to social isolation, but also financial impact. And so we can talk about this throughout our time together.
Dr. Michael Consuelos [00:02:35]: But part of that article that I wrote, that opinion piece, was really to help people think about rural America, the financial situation that hospitals in those areas have and really their ability to provide evidence-based, patient-centered care specifically around behavioral health to their communities. And the barriers that are in the way. And how can technology and other ways to partner with patients and advocating for patients really– so they can avail themselves of some sort of treatment and engaging them. I guess that’s another piece is we could talk about is really patient engagement because that is clearly an evidence-based way to improve behavioral health is to make sure that the patient is engaged with their provider and with– I’m sure we’re gonna talk about apps and other technology, but they’ve got to use it in order to benefit from it.
Kurt Schiller [00:03:29]: And, you know I really want to encourage anyone listening to check out the article. I would even say, you know, it would be awesome to kind of pause the podcast, go read it and then come back. It’s a really wonderful write-up of a very challenging situation. It’s one that, you know, my background is actually in Medicaid managed care prior to kind of moving into the technology space. And so many of the challenges that you were describing in the article really hit home for me, as you know, especially in terms of engagement, trying to build these relationships that don’t exist or aren’t normalized. But before we get too far ahead of things, just for anyone who maybe isn’t particularly familiar with rural healthcare or with the challenges of delivering behavioral health, you know, in the here and now. How would you layout the challenge you’ve covered in the article?
What’s making behavioral health in rural America so inaccessible?
Dr. Michael Consuelos [00:04:16]: Yeah. I would even go past the article since they had a word limit for me. But so- so a large proportion of the United States lives in what I consider rural America. And so there are several challenges that are faced. So the first thing I’m going to talk about is workforce challenges. And so there are clearly large areas, large swaths of America where there isn’t enough healthcare and then specifically behavioral health professionals to take care of the surrounding region. And so there’s a couple of factors around that. And one of them is that we’re seeing trends in healthcare professionals to stay near where they’re trained. To stay in urban areas because of economic factors, pay. There is a factor such as a lot of health care providers tend to have their partner or their spouse also be in healthcare, which is interesting. And so then they also need a job and healthcare and it’s hard to move out of that area. They, you know the schools, universities, theater, all those things you get in the city, you don’t find in rural America. And so there’s a real challenge, and one thing I speak to my clients in rural America is just recruitment and retention of healthcare professionals. And then the other thing we’ve been seeing is that in areas where there’s even just in specialties, specialists who provide just ancillary care that is actively recruiting those people. And so community colleges and other trade schools are closing in rural America. Even those sorts of patient-facing lower-level types of care jobs are not being filled. So there’s a huge workforce issue.
Dr. Michael Consuelos [00:05:46]: Then there’s a finances piece because of rural America being a large and aging part of America, really, and a lot of young people are moving to cities. So you’re gonna have a larger Medicare population. And then also because of other financial issues, a large Medicaid population. So the payer mix is not as beneficial to hospitals as they may be in more suburban/urban areas. So the finances to provide care that may not be very remunerative, which Behavioral health is not. It’s not something that gets well paid. It’s not procedure-oriented like cardiology and neurosurgery and orthopedics and cancer care and those kinds of things where those high reimbursement rates. Those specialties aren’t usually as available in rural America, which then helps offset the costs of behavioral health. And so then there is this lower, shallower pool of funds to provide outreach to community health. You mentioned population health. Those kinds of programming can’t get support.
Dr. Michael Consuelos [00:06:43]: So workforce, financial, and then, you know, I think there’s also a little smaller things. But I think those are the two big things that really face rural America.
Kurt Schiller [00:06:51]: You had a really interesting point in the article that to the extent that behavioral health comes up in a lot of rural communities, it’s often going to be something that comes up with a primary care provider who may or may not- probably won’t have the training and actually, you know, delivering that care if they are– he or she is able to deliver it. It probably won’t be reimbursable, or if it is, it’ll be a very, very small chunk compared to what the business driver that they actually want to be doing with their practice.
Dr. Michael Consuelos [00:07:20]: Yeah. So, yeah, very, very true. And there is– so all of the primary care specialties, pediatrics, telemedicine, internal medicine have at the Air Academy Association level been doing a lot of work to advocate for the payment for primary care physicians to take care of more behavioral health and also providing training and providing tools and tool kits. And so that’s been helpful. But you’re absolutely correct. And that’s also the time and expertise. It’s also an aging population- again bringing up the aging thing, but that the providers on the numbers right from you– but the providers in rural America tend to be on the experienced side, we’ll say, right, the older side. So they have also haven’t had the benefit of maybe some of the newer medical school residency programs that have combined more behavioral health education into their training programs. Right. So with that, it’s– it is an issue, but they’re the only show in town, so to speak. So one of the things I really advocate for is tools, applications, programs that allow the primary care provider to take care of those populations in their office. It’s closer to home. They have a relationship. And because of also co-morbid conditions, meaning they have behavioral health and maybe also diabetes or hypertension or other illnesses. That physician is taking care of those problems already. And so adding on the behavior help piece makes sense because those other conditions worsen as your behavior, health, anxiety, depression, those kinds of things pile on, usually your health also, it gets impacted. So it makes all a sense from that perspective.
How can focusing on patient engagement improve digital behavioral health?
Dr. Michael Consuelos [00:08:55]: So definitely providing technologies and again, in my article, I mentioned Neuroflow, which is a behavioral health platform that does that well. There’s other platforms out there that do that. But they have, you know, the important piece is that patient engagement and giving that provider evidence-based, so if you’re a provider listening is, evidence-based patient engagement, easily accessible options, applications, that then report that information back to you so that you spend less time having to do the interviews and those kinds of things and also tracks the patient over a period time. So as you know, there’s a lot of evidence-based sort of surveys or patient PHQ-9 as other things that basically allow the physician to see at what level their depression may be. And that takes time in the office and that can be delivered on a regular basis to the patient and have that data rolled up into as a screening form into their electronic medical record or how are they doing it? That also saves time.
Kurt Schiller [00:09:56]: I’m really glad that you mentioned the patient engagement angle. So, you know, I mentioned my background in managed care previously, and I worked in member engagement and communications at a Medicaid managed care organization. From personal experience, I can tell you, one of the biggest challenges was that patient engagement for– within managed care was so often reactive and not proactive. You know, like the stereotypical patient journey that we were thinking about was– often it began in the emergency room when someone had a health episode that required them to go to the emergency room or a lot of people, you know, unfortunately, have to rely on emergency rooms as basically their primary care provider. And so getting people to then engage beyond that and even get to where they could be evaluated for whether they were struggling with a behavioral health issue was itself a challenge. Even apart from the challenges of delivering that behavioral health and you know, I was working primarily with more urban populations where you have maybe less of a challenge with things like transportation, providers, you know, maybe a bit more available.
Kurt Schiller [00:11:05]: So even just from a patient experience and engagement aspect, it’s such an interesting challenge. People have a tendency to maybe look at — when I say people, I mean, you know, the kind of the layman population maybe has a tendency to look at behavioral health as a nice-to-have instead of as a need-to-have, or they maybe take it for granted as something that like, well, we know how to provide these services. We have things like Medicaid and Medicare. Why don’t we just provide them? And I think what a lot of people maybe overlook is the fact that there is a real healthcare literacy or even like health coverage literacy challenge. Even as someone who has the privilege to be able to engage with my healthcare coverage and spend a lot of time thinking about it, it’s hard for me to keep track of whether behavioral or mental health treatment is included in my coverage. It may not be even something that people are aware of or have the time to think about whether it’s something that is included in their healthcare coverage. I mean, how do we start trying to fix this where it’s something that is maybe more normalized and is more of a part of the conversation?
How is the Coronavirus pandemic pushing telehealth forward?
Dr. Michael Consuelos [00:12:15]: Kurt, so many good things in there. My mind’s racing here. So one of the first things that I want to make sure I hit and we can talk about a bit more is in this interesting time of COVID19. One of the theories that I’ve been sort of thoughts that I’ve been trying to espouse is the patient acceptance of technology in their home or in their daily healthcare experience or put in air quotes, right. What you mentioned was like sick care. So right now or before COVID19, a lot of personal experience around healthcare, unless you had an infant who was being seen on a regular basis or you have a chronic illness or you’re on dialysis, or you’re really obligated to be seen on a regular basis. Most people see the hospital as episodic. If you’re sick, that’s where they go, right. So it’s an episodic sick care model as David Nash and other folks would talk about. Right. So that’s our experience. Now we have the experience where we’re isolating in homes. We are– if we are having interactions with our healthcare providers, it’s actually happening in the home. And so people with chronic illness, folks with diabetes or heart failure and other serious medical illnesses who would only go in maybe a couple of times a year to see their physician for routine care and then only go to be seen sick when they’re sick, that routine care now is being delivered remotely.
Dr. Michael Consuelos [00:13:41]: And so now that technology is being potentially accepted. So one of the things I’ll talk about is that this may be an opportunity as we know that telehealth is being- all of a sudden, for years, and I’m was working for the hospital association here in Pennsylvania. We would work — work with the legislators to try to find a way for there to be coverage to match behavioral health coverage like you would have physical care coverage and also care about payment parity, meaning the time that you spend as a professional, you actually get paid the same amount if you deliver that care via telehealth device vs. in-person, right. And as a professional, my time is valuable whether I spend 50 minutes with you face-to-face whether I spend 15 minutes with you in person but through a telehealth experience, it’s still my time. I still have you know, we can talk about whether or not the cost of delivering that is different. For a decade that’s been discussed and all of a sudden overnight bam– it is now being paid for. And now I think the patients who in the past may have thought that was not a great way to be receiving care are now having to accept that. That’s a huge fast forward in that patient experience process that you’re discussing. And that change and that philosophy. So I think there’s an opportunity in healthcare. So we’ll use that broad stroke there. So that means care delivery, payment organizations, and then in the sort of digital health technology space, there is a now sort of mushing of time together saying okay what we thought was gonna take decades is actually gonna be overnight, like you can do this.
Dr. Michael Consuelos [00:15:13]: So that’s the first thing. So you mentioned a lot of things. So that’s the other piece. And then how does that get translated into more continuous monitoring of behavioral health, which is a chronic illness that is already stigmatized, meaning that, you know, obviously you don’t wanna be sharing that you have a behavioral health problem. But then even going into a psychiatrist/ psychologist’s office that walking to the parking lot, people have that– many times that sense– I don’t want to be there. I don’t wanna be seen there. I don’t want people to know that I’m going there. But now, if this all works out with a telehealth solution writ large that is paid for, then some of that maybe engagement occurs on a regular basis. And if you can, you can journal how you’re feeling on a regular basis and you’re using technology to pick up the different screening questions and the mood swings and how many hours you’ve slept overnight and all that is tracked longitudinally. Then you can start saying, hey, a person who has this level of anxiety or depression is now getting worse. And because they’re journaling on a daily basis and they’re doing their screening questions on a regular basis, you can get to them sooner. You can get them to maybe have an interaction with them or change their medications or if they’re getting better, you may not see them as often.
Dr. Michael Consuelos [00:16:27]: So in fact, that may be a way for us to have more capacity, right. Why see somebody every week if they’re journaling and if they’re doing all these different activities, evidence-based activities that– meditating and whatever else– maybe can spread them out and you can see more people. So that’s the first thing– I’m sorry, a big mash-up there of things. But I think that this allows us a greater piece.
Dr. Michael Consuelos [00:16:45]: And then the healthcare literacy piece I completely agree. And insurance literacy. Nobody understands– most the time, why is behavioral health and physical health completely separated? And depending on your state, there’s carve-ins and carve-outs and it’s madness.
Kurt Schiller [00:16:59]: Well, one of the most interesting things that I’ve always found is in terms of engaging directly with health coverage. Often times it seems like, with behavioral health, the terminology or the services won’t even be standardized in a way that makes sense to a patient. You know, someone might get to where they’re saying, I need to talk someone, I need to do say like– like talk therapy. And if you ask the insurance provider, they may say, oh, well, we don’t cover that. But then if you go and look at, say, like a provider, you know, search index, you’ll find someone who from a patient’s point of view is providing behavioral health. And it turns out that it is coverage because, well, you asked about talk therapy and the actual terminology that you should have asked about is slightly different service that is covered.
Dr. Michael Consuelos [00:17:43]: Right.
Kurt Schiller [00:17:43]: It’s not a field that seems to be covered in a way that will make sense to a patient. You know, there’s challenges, enormous challenges to this, too, obviously. But, you know, if you say to yourself, I have healthcare coverage, I can see a doctor for something in some sense. And then you try to translate that into the behavioral health world. And suddenly, you know, even someone who has a high degree of health literacy may suddenly lack the language or the terminology or the skills to navigate their healthcare to be able to access those services. I can’t even imagine the added challenge of that when you’re dealing with things like the social determinants factors, the transportation factors that also would come up in specifically, you know, rural communities as well.
Dr. Michael Consuelos [00:18:21]: No, I completely agree with you that it’s– you know, people use this analogy all the time that’s somehow easier for me to find a flight to anywhere in the world on my phone. But I can’t find an appointment with my doctor, right. Or find the doctor who can take care of my illness. I can order everything under the moon specifically delivered to my home, but it’s difficult to figure out how do I get medications delivered to my home or durable medical goods delivered to my home. It is, I think, a challenge in that there’s such a fragmentation, I guess, of all this. And you’re absolutely correct in saying that it’s difficult to– if you don’t know how to access or don’t use the right keywords to access the care why is that a boundary? And then the integration of our medical records in those kind things, I mean, basically, we have a great billing system that tracks encounters from a transactional perspective, but does a really poor job in trying to figure out how we’re doing as human beings. And we do have obviously lots of value-based payments that sometimes process factors are calculated in there some have their outcomes. But we do very little to really, I think– better understand how does that– that’s always on a transactional perspective, right. Those are based on electronic medical records or the different bills, they aren’t really tracking the person or let’s say holding the provider accountable to make sure they’re following an evidence-based path that allows some leniency and some obviously professional divergence when necessary. But there isn’t enough of that kind of tracking. And I don’t know– and maybe we’ll get there at some point in time. But what excites me the most about some of the things you described is that we’re at least having these conversations.
Dr. Michael Consuelos [00:20:03]: Five, six years ago, nobody was home at opioids and addiction. Now it’s– we’re talking about it all the time. It was two or three months ago nobody was talking about public health. Right and now, everybody knows who runs this– you know, everybody knows Anthony Fauci– like he’s probably got more name recognition than the top 10 movie stars, right. So I think at least these conversations I’m hopeful and worth the fact that we’re spending time today to have this conversation and people are hopefully listening to this, is that that change will slowly start to evolve into action and that it that there were in such– such ambiguous times that we’re in that we are with the rulebooks are being thrown out the window, that there is no guide to what we’re doing right now in this current situation with COVID19, that hopefully in that creative destruction that is occurring, that we’ll find some new solutions, that people will take the time to say there’s a better way of taking care of behavioral health, and there’s a better way to support rural health in America than what has traditionally been really a transactional rearview mirror-facing perspective.
Kurt Schiller [00:21:11]: I want to talk a bit more about the technology aspect because you’ve mentioned that a few times. And I want to make sure that we lay out exactly what we mean when we talk about telehealth and what we talk about, you know, technology solutions to this. My experience with telehealth has been it seems like it became available or at least more common in a direct-to-consumer way that you’ve mentioned evidence-based a couple of times. I’ve noticed in the past couple of years that there have been a lot of technology companies that have started providing some form of what maybe comes right up to the line of behavioral healthcare. Sometimes it may technically be health care. Sometimes it’s just a form of not quite healthcare. But to a layman, you might understand it as being behavioral healthcare for telehealth or a technology solution to be a viable clinical tool for delivering behavioral health, like what must it do? What are some of the prerequisites to maybe set it apart from some of the more casual, direct-to-consumer offerings that have been out in the market previously?
Will delivering behavioral healthcare through telemedicine benefit patients and providers?
Dr. Michael Consuelos [00:22:12]: That’s an awesome question. So let me take a step back in healthcare providers have, I think, relied on the person-to-person ” I need to do this with a person in the room, in front of me. And I think in the areas where physical contact was not necessary, you saw a lot more telehealth possibilities. So tele-derm, right. So to look at a high-resolution shot of a mole on your skin is probably just as good to see the person in the room and you can say, yep, this be seen. Obviously we’re talking about telebehavioral health, right. So telepsych– is what most people call it, having that interaction face-to-face or be a phone is it really not that much different than being in person. So I think in the areas where we had that capability, there was some movement. But now what we’re seeing is this land rush, this gold rush towards doing as much as you can via telehealth and home-based care, right. So home-based care is also another space. So back to your original question, so I just want to say that it’s not like we’ve never been– you know, we are doing this, but it’s little pockets. And the question is, how do we move forward?
Dr. Michael Consuelos [00:23:21]: So we talked about patient engagement like 10 times already, I think that is a key. I think thinking about it and I think there’s plenty of cues we can get from everything else happens via our phones and our computers where behavioral economics theories really play a heavy role, right. So gamification of interaction. So if you have a meditation app like I do and I meditate so many days in a row, I get a little sticker or a little a button. You know, If I do it 30 days in a row I get a little star something or like a little metal, right. I mean I can’t eat that, I can’t put it on my wall, but it does provide that little dopamine rush, right. Like that little bit of like a reward, reward? Right.
Dr. Michael Consuelos [00:24:00]: So I think that applications that use behavior economics theories in gamifying and tracking and providing feedback to the user is much better than I’ve seen some other types of applications where it’s sort of like –a not really a dialog with the application or with the end-user, it’s sort of– you’re putting stuff in. You can sort track it or whatever else those reminders, but it’s very passive. So the more you engage. But what makes an application highly almost addicting, I guess at some level at the brain behavioral economics perspective, because I think that the greater engagement you get with the patient. And obviously then you start talking about ease of use and all those kind of things. But I don’t know, turn the tables to you a little bit, what are your thoughts around what is an engaging interface that should be looked at?
Kurt Schiller [00:24:55]: Yeah. So, I mean, there’s a lot to unpack obviously. The first thing I’ll mention is, you know, that sort of behavioral economic theory for good or for ill has been a very common factor in the consumer market for a long time. Even if you go back maybe eight to 10 years, even a little bit further back, you started seeing especially video game companies, especially mobile video game companies, were explicitly hiring people with expertise in behavioral management and psychology. Again, I say for good or for ill, because from a video game standpoint, often they’re coming right up to the edge of, well, how can we make this addictive? You know, in a sense, which, you know, I think you can look at and see that’s an extremely negative use of these sorts of techniques. The thing that jumps out to me, and I’m someone who has played a lot of video games in my day. And one of the things that set apart an addictive video game or that, you know, to maybe put it in a less stigmatized term, a video game that you are going to want to engage consistently with. Because I mean, really, the difference between addiction and good engagement is whether it’s having a positive or a negative outcome on you as a person, right?
Dr. Michael Consuelos [00:26:13]: That’s exactly right.
Kurt Schiller [00:26:13]: You know, if our health care experiences were addictive, that wouldn’t necessarily be a bad thing. That has to be a consistent thing. It has to become at some level like a normalized part of your life where you mentioned, you know, like meditation apps, really. This is one of those moments I wish I had our Head of Design Len Damico to jump in and start talking about this. But I’ll say that you know, it has to become something where you are expecting it. It’s not something that just suddenly shows up on your phone every five months or someone has to nag you into using it. If someone has to nag you into playing a video game, it’s not a very good video game. Somebody has to nag you into playing an app, it’s not a very engaging app.
Kurt Schiller [00:26:55]: I think there’s probably a lot that can be learned from looking at successful engagement based applications, especially social media, that really work to become again, for good or for ill, a part of your everyday life where, you know, you’re waking up in the morning, you’re thinking, okay I got to do this, I’ve got to do that. And I think a big part of that for, in terms of how can that be applied to behavioral health or to health care in general, it needs to become something that you’re thinking about that is normalized. It isn’t a chore. It isn’t a task that you go oh gosh, I have to deal with this thing again. Because, you know, if you have an app that you don’t particularly like, you don’t have a good experience with it and it just nags you all the time. You’re eventually just not turn off the notification and then you’re out of the system. You’ve fallen out of the loop. I think obviously, you know, there are real design challenges about building approachable, enjoyable– you might say delightful, you know, healthcare experiences that aren’t off-putting from a user experience standpoint.
Kurt Schiller [00:27:53]: And so there is also a real challenge of how do we, as people who are developing and designing patient experiences, make those patient experiences feel like the stuff that an end-user already is familiar with and already likes, while still also fulfilling the specific obligations of working within healthcare. Obviously, Facebook can get away with doing things that are maybe effective that a healthcare provider can’t or and frankly ought not to be getting into. Especially when you start looking at things like privacy and data use and data portability, you know, Facebook can get away with a lot more than a healthcare provider should frankly be able to get away with it. The solution there is to fix Facebook, to be clear, not to fix the healthcare providers.
Dr. Michael Consuelos [00:28:34]: I think you and I are completely aligned in that. And I agree that’s that engagement piece, that gamification, that behavioral economics piece to keep the patient engaged at some level. And anybody who is listening to this, who is in this field, take a real critical look. Or if you’re in the early stages of your product development as you’re putting together a minimum viable product to really scour it really hard say am I my really doing the best job I can or our team can to engage the patient and move out of the “I know what’s best” and I’m gonna click off these boxes to make sure this content is there and turn the tables and go, how would I want to consume this content at what pace and those kinds of things? So a couple of simple things. Both my parents are over the age of 80 and have now finally really got into the Zoom, right. Everybody is doing these zoom things right. So I’ll just– I’m just gonna use this as an example– I don’t wanna beat up on Zoom because they’re doing a great job of giving a lot of free availability to schools and individuals so In no way am I, you know, downplaying that part.
Dr. Michael Consuelos [00:29:39]: But– if I were king at Zoom, I would say, gee, there’s probably a lot of folks who aren’t very familiar with my product, who probably are my parent’s age, right. And why do I have someone like me, a physician– anything else, try to explain to my parents how to get their Zoom up and running, right. Why isn’t it– when they open up Zoom, you could easily, if you want to, you know, take a quick three-question survey of what your preferences are, your technology abilities, whatever it is, you know, whatever. And it just like walks you through those pieces so that the very first time I don’t have to spend a half an hour with my parents going “down there in the corner, push the, you know, mute/unmute button or up on the top part is the gallery view”. I’m doing it in real-time. So what you wanna talk about it as hospitals that– I’ve witnessed this personally and looked at different organizations– there has not been a good rollout of telehealth either to the individual consumer or to the physicians who are using them. The providers are using so I’m gonna shift gears here a little bit and kind of maybe bridge the gap on the patient experience.
Dr. Michael Consuelos [00:30:38]: So experience is what are we doing as healthcare providers or the healthcare industry to make sure that as you’re developing applications or as a hospital practice, whatever you are, you’re doing a great job into making sure that the rollout of that technology is accept– because part of something is, well, how easy it is for that end-user to use it, right? But also the experience of the person who’s now consuming the other end of that experience, right. So how easy it is for providers and is it really a workflow issue that can be put into their EMR and those kinds of things?
Dr. Michael Consuelos [00:31:10]: So I want to kind of just bridge a little bit to the engagement piece is that successful applications, yes, we’ll use behavioral health economics, but also they should spend some time in making it easier for each you know whatever your avatar is for your users, your four or five top avatars? And one of them has to be an 80-year-old, you know, X whatever government worker living in North Carolina who’s got a little bit, you know, a little bit of, you know, wears glasses, you know, myopia and has to, you know, use larger font everything else. Like, is your user experience optimized for that person? Yes. No. And if it’s not, are you just going to not let them use it? Right. And then on the consumption of the provider side is what are the avatars for that? Is that a fully integrated health–care system which has all of the deep bench and I.T. department who could easily implement all that stuff into our EMR? Or is it a small practice with two or three people with no I.T. department? How easily is your application now gonna be consumed for the health of that patient in the community? How is that practice gonna now use that application to deliver better care? I’m getting a little bit into extremes here, but that’s something I think people need to think about that are in this work.
Kurt Schiller [00:32:22]: From a product-design standpoint is there is a few really, really interesting challenges. The first one I would say, you mentioned, you know, figuring out what does your MVP look like. And one of the biggest questions you always have to answer and that is determining who is my ideal customer? Who is meant to be, in terms of a product, purchasing this product? And one of the biggest challenges in health care products is that oftentimes, if not usually, the purchaser of the product is not the same person as the end-user of the experience.
Dr. Michael Consuelos [00:32:52]: Say that one more time because I don’t think–.
Kurt Schiller [00:32:53]: Yeah. Yeah. You know, you may be selling to a hospital system and you are selling. You need to develop an experience and features that are impressive to a purchaser at a large integrated healthcare network who has a high degree of expertise in evaluating this as a healthcare tool. But then you ultimately expect it to be used by someone totally different– totally different world. And it’s very easy to develop an experience that someone will want to buy, that the end-user will not want to use. And you can look at this and things like patient portals.
Kurt Schiller [00:33:27]: Patient portals are usually designed for people who are familiar with patient portals and are going, “Okay we need to provide these features. We need to provide these experiences. I know that this has to be this way for regulatory concerns or for privacy.” And then immediately you try to bring in the user and they say, “OK, I want to look online and see when my next appointment is”. If you’re looking at a restaurant reservation. You just open up the app and it says, you know, it is what it is. If you’re trying to access your patient records, you may need to talk to the healthcare provider, get a paper code printed out directly from the front office staff. You then need to go to a separate website. And there’s very good reasons from the provider’s point of view why this needs to be the case. The result is a patient experience or a user experience that nobody is going to want to use.
Kurt Schiller [00:34:12]: To go back to the video game discussion. One of the big reasons that mobile games took off alongside with social media is that they tapped into an audience that was not traditionally seen as a video game playing audience. So, you know, if if you go out and you buy an Xbox game or a PlayStation 4 game and you install it, you put the disc in. I, as a person who has grown up playing video games, know that this button, without looking at the manual, without reading any prompts is probably the jump button. Just because that’s a typical experience, that’s usually how video games are. The audience that was reached by mobile games did not have this lifetime experience of “I know how video games work”. I know how video games function. They succeeded because they designed an experience that somebody could come in knowing nothing about the app, nothing about the norms and standards of dealing with video game technology. And often was like, here’s the big button. You push the big button, the thing that you want to happen, happens.
Kurt Schiller [00:35:09]: And I think to a certain extent, healthcare experiences need to get to the point where maybe there will never be a push the one big button. But it should be obvious when you come into it with an average level of health literacy for the population you’re trying to reach will be able to use your product. If you get to a point where you’re frustrated that “Aw man, users don’t understand how to use my product”, that’s what I would describe as a “you problem”, not a “them-problem”. We really need to start centering on their experiences and not the expert experience basically.
Dr. Michael Consuelos [00:35:42]: Yeah. So we started this conversation talking about rural health. And so the reason I’m jumping back to that is that if you’re providing an application for a highly sophisticated top one percent of the economic scale, you know, you’re right. Your minimum viable product of being very different. But it is a challenge, as I think, about rural America and their challenges and even broadband, right. That’s a huge issue. And a lot of money is being finally put into that. So, look, it’s been trickling in, but now the FCC and other organizations are really pushing the gas pedal on that, which is great. So if it’s dependent on a, you know, whatever a gigabyte download speed or something ridiculous, it’s not gonna happen in rural America, right. So how can you if that’s if that’s what you’re developing to make sure that somehow, no matter where you are in the United States, somehow everybody’s on Facebook. But your kind of comment– they’re all playing bejeweled or whatever those games are, I don’t play those games. So it is 100 percent correct. And it is difficult. It is difficult to do that. I really liked again, the reason I asked you to repeat it is that I’ve been playing in those meetings either on the health care system side, right, being the buyer and hearing all the features and attributes and value propositions of a technology solution.
Dr. Michael Consuelos [00:36:59]: And I’m on the other side, the person who’s trying to get it sold. We all kind of reflexively go back to that. We sell that to the chief medical officer or chief information officer or the CEO, the chair of whatever department in case of behavioral health, the Chair of Psychiatry, or the Behavioral Health Center, whatever it may be. But at the end of the day that has to be used by the individual providers and then the consumers itself. And that is– that those are far and few between organizations– I’m sorry, application companies that have kind of figured that out.
Dr. Michael Consuelos [00:37:27]: And then also, you know, the other thought that I have– a question for you is it’s the wild, wild west out there. I mean, there is stuff all over the map. There’s tons of applications. And I guess from, you know, maybe I spent a lot of time thinking about like, how do we bring some order to this kind of crazy marketplace that we’re in? Because I sometimes I have to do these sort of digital or telehealth kind of like assessments and those kind of things. It’s almost like the eye of the beholder. It’s like, well, what do you want me to tell you? Yeah, it looks good to me, you know?
Kurt Schiller [00:37:56]: Great question. I think that one of the big challenges right now is that there are so many invisible factors that have no direct patient impact or clinical impact. Or again, you talked a lot about evidence-based, outcomes-based. There’s so much of the marketplace that is being driven not by healthcare outcomes, but by, say, your ability to sell to a large provider network, your ability to integrate with specific EHRS. What integration capabilities are available? What population has the best chances of reimbursement? What specific services are available for reimbursement? That it’s really no surprise to me that the marketplace is so all over the place in terms of what these products are trying to do. I think right now people are still trying to figure out what the business model needs to be for telehealth. I remember thinking back to when I was working in managed care.
Kurt Schiller [00:38:56]: I remember evaluating telehealth solutions to potentially be provided to members. And one of the challenges was for most Medicaid plans, I believe you cannot ask for any kind of payment at the time of service. You cannot bill the patient and so many of the telehealth solutions that were out there in the marketplace were designed to direct bill with a credit card the end-user and so to be able to make that work for a Medicaid or Medicare population, which I believe is around 60 percent of all people are covered by Medicaid or Medicare or CHIP. It was a nonstarter without changing the experience. But from a business model standpoint, of course, it’s preferable to just get credit card info and charge the end-user directly.
Kurt Schiller [00:39:41]: And so I think as long as we have these kinds of strange factors that where the market is incentivizing things that have no impact or even possibly a negative impact on patient outcomes, you’re not going to get a sensible-looking market. To turn the question back around on you– kind of hinting at and have mentioned a couple of times like the regulatory landscape and the impact that that has on this. Like in terms of the original challenge of talking about delivering behavioral health, whether it’s through telehealth or traditional providers, like what needs to change? What what is the best case outcome for making the solution of this problem into a reality? Whether it’s developing better products or getting more providers in rural areas?
Dr. Michael Consuelos [00:40:25]: No, I think that is a great question. So what I would say to the last part of your question is getting more providers in rural areas. I am bearish on pessimistic that we’re gonna have a huge landslide of behavioral health specialists going to rural areas, right.
Dr. Michael Consuelos [00:40:39]: So then to me, it’s a– what I’ve shared with other people in other organizations I have consulted with is that you’re in a resource-constrained environment. And when you’re in a resource-constrained environment, you have to think about things that as– what I call force multipliers. And so I was in the army for six years and– we would– but there’s things in the battlefield or whatever you’re doing, a technology that allows you to complete your mission with a limited number of forces on the ground or the air or whatever else literally means what it says. It’s a force multiplier. So how do you get the number of behavioral health specialists that you have available to you to see more people have greater capacity and have a greater impact on their population? So a couple of things on that. On the regulatory piece, I think there’s a huge– I think the Pandora’s Box of telehealth has been opened and I think it’s gonna be very hard for someone to try to close that. You’re gonna have a huge uproar. And I think finally, both on the federal side and on the private payer side, we’re going to have continued release or relaxation of what was issues before– a lot of special interests really were holding things back that we’re gonna continue to move forward in telehealth. If that doesn’t happen I think we’re going to go– it’s gonna be a huge issue. I think that the force that’s going to continue to allow that to happen is– I think that the COVID pandemic is going to be something that could be around for us for a couple of years. It’s 12 to 18 months until we get a vaccine at the minimum.
Dr. Michael Consuelos [00:42:01]: The other thing we did talk about is I actually am an expert in pandemic response and business continuity. It’s been part of my life recently and in the past doing H1N1. And the huge difference between H1N1 and now is that we didn’t have already a stock vaccine that needs to be altered to go into H1N1. We had a flu vaccine, we just needed a little bit of time. Technically. So Sirs and Mers, the two first coronaviruses that occurred, had– those vaccines never got our Phase 1 trial. We’re now finally in Phase 2 trial for this. So long way me saying is that we’re going need to be having telehealth solutions like the next 12-18 months. Even if we have pockets of America who are opening up more and more. I think there will be pockets where there’s going to be restriction of travel in large groups and those kinds of things. So I think the safest thing to do is for there to be telehealth being a continued movement. And with that is the payment piece, Kurt– is the piece around making sure that we may not get payment parity around telehealth, but at least we get universal coverage and some sort of decent amount of payment because what that allows organizations big and small is to continue to invest in the telehealth technology and buying the applications that you and I are kind of describing, right. So if you don’t have the resources, no matter how good they are, it’s hard to buy them. And right now, this huge– so one out of four– one of the four rural hospitals are in danger of closing. Every day that passes without some sort of stimulus for rural hospitals, that number is going to go up. So there won’t be any hospitals to deliver care. So there has to be payment. So there has been a road to the releases to allow it to happen again, again across state lines for some licensure portability issues around that. That again, that’s been relaxed. And for those people aren’t aware of that, licenses in medicine are like driver’s licenses in states. We get them for each state. But you can’t– it’s as if you had a Pennsylvania license and you couldn’t cross into New Jersey because you don’t have a New Jersey driver’s license. That’s the way it is for medical licenses. So to deliver, especially in rural areas where there could be a provider that’s across the state line to have them more easily provide care to a larger swath of communities around them. That is obviously helpful. And specialists, to recap. So telehealth regulatory payment for telehealth, licensure portability are big pieces. And then it’s interoperability issues, right. So I think– you’re nodding.
Why is prioritizing interoperability in digital health apps so important?
Dr. Michael Consuelos [00:44:13]: The audience can’t see this, but he’s like–
Kurt Schiller [00:44:15]: Making a face and nodding yes.
Dr. Michael Consuelos [00:44:17]: Like interoperability, right. So for lots of– talk about, you know, for whatever reasons, we have three or four very large EMRs that are not interoperable. Sort of health information exchanges across the United States were supposed to be the answer or some of that right, so that people could do data dumps and transfers of 837s and ADTs or admission discharge transfer communications. And somehow that was going to flow seamlessly between organizations and track your patients. Not happening for the most part, right. So another piece that I think is the interoperability. And so as people are developing applications and I know that’s an issue with you said that you said, you know, are they epic-friendly or Cerner-friendly or whatever-friendly.
Kurt Schiller [00:45:01]: Right.
Dr. Michael Consuelos [00:45:01]: That’s a big piece. But I think within applications, you know, so are there applications that allow themselves to also be interoperable or more easily some sort of exchange of information? Because I’ll give you an example. We’ll use behavioral health as an issue, right. So if you have a behavioral health platform that is tracking certain things within a patient’s lifetime and they also have diabetes, right. So in a perfect world, the diabetes application would somehow be also communicating with the, you know, all privacy and everything else, blah blah blah. With your behavioral health things, because your level of activity level, sleep, when you eat, when you don’t eat can affect both those things. But if you’re living in these two totally separate, siloed systems, you may be getting as a patient cues to do different things or different feedback or whatever it may be because they’re completely siloed. But I don’t know– what other things you think I should– we should talk about that.
Kurt Schiller [00:45:57]: I think that the interoperability aspect is absolutely enormous. This is a question that as a business, Arcweb gets a lot of, you know, “we want to develop a healthcare product and we have– we understand that EMR integration is important. How hard is that?” And oftentimes the answer is well– frankly, very hard.
Dr. Michael Consuelos [00:46:16]: For good reason, because the EMRs want to be–they want to put up big walls. Now, I’m sorry to interrupt you, but you know like for example, Epic is doing the app orchard or whatever they call it, you know. So I think they’re moving a little bit towards that? Don’t you think? Or–
Kurt Schiller [00:46:27]: We actually have a fair bit of experience specifically with Epic integration and with the App orchard and they’ve definitely taken enormous strides in making the information about integration, about the best practices that they’re looking for, a significant improvement over even where it was a few years ago. I don’t think that anyone would credibly argue that it’s anywhere near the ease of integration compared to like a consumer application that is integrating with even frankly, integrating with, you know, banking systems. Often times a much easier technological challenge or bureaucratic and, you know, business challenge than doing EMR integration is. And so, again, talking about what are things that are influencing the success or failure of products or solutions that have nothing to do with clinical outcome. That’s a really big one. Now, there is– there was legislation that was passed at the end of the Obama administration the 21st Century Cures Act, which we have have been writing a lot about, that is a very vague way, said, well, electronic health records need to be interoperable. You need to have APIs. And that was– the actual legislation, didn’t provide, you know, in the way that that legislation often doesn’t– didn’t provide exactly what well, “What is an API? What do you mean by it must be? What do you mean by interoperable?” And so the ONC and CMS having been working through kind of operationalizing what does that legislation mean? There have been a number of drafts of the final rule and they’re currently going through kind of the final revisions and comments and roll out of it. But the long and the short of it is there are, there is a hopeful scenario on the horizon where, you know, interoperability and data portability and the availability of APIs that telehealth solutions absolutely need to be able to take advantage of well, will not just be a nice-to-have on the part of EMR providers, but an absolute requirement for doing business at least if you want to get any kind of reimbursement from the federal government.
Need help navigating the new regulations?
Kurt Schiller [00:48:35]: And I think frankly, you know, that the government gets a bad rap for regulations a lot. But when you look at, I think electronic medical records, really the reason that they were adopted in the first place and the reason that the market has– is now improving is because of regulations. And so I think, you know, it’s always a question of how will it ultimately turn out? How will it actually be it be enforced? What will it actually look like on the ground? Which I don’t know, you know, can’t say. But the signs are currently hopeful, at least compared to where they were five or six years ago, frankly. So I think that’s a huge hopeful indicator for that entire piece of the puzzle. I don’t think that that will itself solve any of the other challenges, but it will certainly mean that people developing telepsych or telehealth experiences can worry less about EMR integration and more about developing a good patient experience. And hopefully, that can become a selling driver and at least a better adoption instead of just– yeah– can this integrate?
Dr. Michael Consuelos [00:49:38]: Yeah. No. I think that you’re actually correct in all those things. I think there is a good movement towards our interoperability kind of Nirvana if we ever get to it. But I think that the marketplace will also at some level dictate that there has to be some interoperability. I think that the organizations who are buying technologies that are more interoperable. I think they’ve seen that unfortunately, we have a couple of behemoth EMRs that have really been pushing back on that. But, you know, the question is, once they– once the two or three big EMRs have 100 percent of the market, right so they have hundred percent cover– you know, they’ve covered all the business– there is no longer new business. Everybody’s converted or switched to whatever EMR. They’re going to be. And what’s their value proposition going forward? What other things can they do in their updates? And I think that’s the space that we maybe have provided a possibility for more greater interoperability. And so I think there’s again, the regulatory piece is so important, as you mentioned, Kurt. I think that the last piece I want to give people some hope for is the level of investment. I think- -again we miss the marketplace. The level of investment in this space is gigantic. You know, I’m not– you know, the numbers of the billions of dollars that are put into digital health. And hopefully, with that, the investment has– because the individual hospital organization providers just can’t– they’re not gonna be able to come up with all the money, right.
Dr. Michael Consuelos [00:51:02]: So there has to be some other investments from other sectors to move this forward. I mean, I’m optimistic that there is going to be a continued momentum towards interoperability, into greater telehealth, into the home acceptance by patients, again, to use the technology because of what’s happening currently. I’m optimistic that from my– I’m a physician, so physicians who’ve been reticent to say, yes, I can do this now, they’ve been sort of forced to do this and actually sample it and touch it and experience it and see it’s not so bad. And there’s some economic drivers to continue to do that. In no way does anybody want to be living through this current pandemic. But I think that one of the silver linings or bright spots has been that it has accelerated what we should’ve been doing over a couple of years and had been taking us decades to do that now we are at a critical juncture to really move forward and step forward if we can figure out the economics, because, again, the hospitals are getting hammered right now. Obviously, the population is getting hammered with a 22 percent, whatever unemployment rate, it’s obviously a restricted environment.
Dr. Michael Consuelos [00:52:11]: But I think– I’m optimistic. And again, I appreciate you having me on this. It’s been great. But, you know, I don’t give people the sense that it’s all doom and gloom from my perspective. Among the reasons I wanted to talk about this, because I think there is a way forward, I think there is actions that organizations, whether it be provider payer or technology companies can take to really move things forward for the patient. Cause I think the day if we don’t do this, if people don’t take the lead and really start knocking down these barriers and move forward, we’re going to take a step back. And I don’t think anybody who wants to be there.
Kurt Schiller [00:52:47]: Yeah, absolutely. And, you know, pulling it all back to the original question of around rural health care and behavioral health. I think, you know, what people need to keep in mind is that all of these factors are cumulative. And one of the biggest challenges in healthcare delivery is that if you put enough barriers between people and their healthcare, the utilization and the outcomes get worse and you know, not that utilization is necessarily the be-all, end-all of outcomes. But, you know, I think in terms of behavioral health, you’re talking about these enormous barriers, whether that’s transportation, socioeconomic factors, patient experience, coverage. If you can knock down even one of those barriers. Man, if you can knock down two of them, it can have an enormous impact on population health, on people’s lives and health. And that I think is, you know, a great point to end on. You know, it’s easy to talk about technology as, oh, you know, technology is new and cool, but it really can make a difference in people’s lives. And, you know, it’s easy to talk about this in terms of doom and gloom and the challenges, but I agree that there is a real opportunity there to kind of move forward and arrive somewhere better.
Dr. Michael Consuelos [00:54:00]: Yeah. Thank you very much for– thank you much for your time and yeah, absolutely. And I think it’s having these kinds of conversations that’s important. I think having the folks that are in the work for technology with the folks are in the work on the clinical side like myself to– and the policy side, to have these conversations and it is important. So–.
Kurt Schiller [00:54:21]: Yeah, well, thank you so much for taking the time and for coming on the show. Dr. Consuelos, where can people find more of you’re writing more of your work? I understand that you do a fair bit of podcasting yourself.
Dr. Michael Consuelos [00:54:32]: Yeah, I did. Well, yeah so I’m a podcast partner co-host to the great Jenny Blake, who wrote a very important book for me when I started my own consulting work, which is Pivot. The only move that matters is your next one. That’s her book and I’m on her podcast. And I can be found on pivotmethod.com/pandemics. We’re actually doing a series around– pivoting around a pandemic. And she has not just me, but sort of her regular co-host, but she has a bunch of really great people across the business. And for example, just recently she had a great episode on Zoom protests for presenters. So it’s like real-life action stuff. But as far as my work specifically, if folks either in the healthcare space payer space or specifically advising around technology, you can please find me at mjc.solutions. That’s my website and you can just contact me through there and I’m happy to get back to you right away. My passion for me is really to simplify the complex so that we all can take care of our patients.
Dr. Michael Consuelos [00:55:34]: And so when I work with companies, I try to put myself in my experiences as a clinician, as a healthcare executive, and also some who have done population health and try to really help organizations improve the health of their communities. So, Kurt, it’s been a pleasure. I can’t believe this time has gone so fast. And as I joke around with my other podcast folks, if you’ve listened to this part, you’ve got to the end of the podcast. Welcome to the end of the podcast club. I appreciate your time. And really, honestly, I hope everyone is doing well. Please take care of yourself. You know, try to stay home when you can, but also stay as connected as you can. So thank you so much.
Kurt Schiller [00:56:13]: Yeah. Thanks so much. Michael, have a great one. And thanks, everyone for listening.
Kurt Schiller [00:56:18]: Engineering healthcare will be back in two weeks with Ankit Mathur of Roundtrip Health, a technology company that’s helping improve patient experiences by removing transportation barriers and healthcare. Make sure to follow us on Twitter and don’t forget to rate us on iTunes or your favorite podcasting app. From Arcweb Technologies, I’m Kurt Schiller.
Kurt Schiller [00:21:41] Product Hacker is brought to you by Arcweb Technologies, a digital design and development firm in Old City, Philadelphia. To learn more, visit Arcwebtech.com. This show is hosted by Kurt Schiller and produced by Martin R. Schneider. As always, thanks for listening. And don’t forget to like and subscribe.