A Look at the Post-COVID-19 Health Care Landscape

[MUSIC PLAYING] Welcome, everyone. I'm Dr. John Whyte, Chief Medical officer at WebMD. And you're watching Coronavirus in Context. How many of you have done a telemedicine visit? Or any of you wearing wearables, trackers, sensors, Fitbits, Apple Watch, collecting data about your health? How is the COVID pandemic going to change the way we receive healthcare in a post-COVID world? So to help provide some insights, I've asked one of the world's leading experts on precision medicine, Dr. Lloyd Minor, the Dean of Medicine at the School of Medicine at Stanford University. Dr. Minor, thanks for joining me.

Thank you. It's great to be with you today. Thank you so much for inviting me.

You wrote a book Pre-Pandemic, where you talk about discovering precision health. Because you talk about we don't just need precision medicine, we need precision health, what do you mean by that?

Well, I think I came to Sanford in December of 2012 to become Dean of Medicine. And shortly after I arrived in early 2013, we began to hear the term precision medicine. There was a wonderful conference hosted by Susan Desmond-Hellmann, who was then the Chancellor at UCSF on precision medicine. And then shortly after that, the Obama administration identified precision medicine is one of the overall health related themes for the country.

Precision medicine is about sick care. It's about using genomics in data science to personalize and to make precise the care for an individual patient with a complex medical condition, like cancer or heart disease. And for sure, we at Stanford do precision medicine. But as we begin to think about our vision for Stanford Medicine, what we hope to accomplish here, we thought we should go beyond precision medicine, beyond sick care, in order to predict and prevent disease more effectively than we do today.

Because ultimately, yes, if we get cancer, if we get a serious complex acute disease, we want to make the treatment precise to achieve the best opportunity for a cure. But would it be better if even before the disease occurred we were able to predict it and prevent it? And if we couldn't prevent it, then to diagnose it much earlier. So that's the goal of precision health to predict, prevent, and cure precisely. But in that order, with a lot of emphasis on prediction and prevention. So precision medicine is about sick care, precision health is about health care.

But we also want to make it more personalized. And in many ways, the COVID pandemic has literally brought care into the home. And it's not just about telehealth, it's also about doing clinical trials in the home, delivering care in the home. And I need to ask you this Dr. Minor. A lot of folks will say, you know what, if we didn't have to pay the physical infrastructure of hospitals, our ambulatory care centers, we could deliver a lot of that care in the home if we had enough of the resources. Do you think that's where we'll be going in a post-pandemic world?

Yes, I definitely do. We're already headed in that direction. In February of 2020, before the pandemic had really settled in here in the Bay Area, we did 2% of our outpatient visits as virtual encounters.

2%?

2%.

OK.

At our peak in late April, early May of last year, we did 70% of our outpatient visits as virtually enabled visits. Now, depending on the clinical service, it's between 30% and 40% of our outpatient visits are virtual. I think we learned overnight that there are a lot of things we can do effectively through a virtual visit that we never thought we could before. And we haven't even begun to start to integrate what you were mentioning. And that is the digital knowledge of our health, either through monitoring of blood pressure or blood glucose, with things that are within our grasp today, but still haven't by and large, been incorporated into typical care flow profiles. That's coming. And being able to integrate data from the home measured about our health with virtual visits and virtual interactions, I think, really ushers in a new era of opportunities to deliver healthcare in the way that it's most meaningful for our patients.

I want to explore that a little further. When you talk about there are things that you never thought we could do in the home that we've been doing, I like to hear a little more about that. Giving chemo is one of those examples. Now, of course, it's not all the chemotherapeutic agents, but we always thought, well, we can't deliver chemo in the home. There's also some reimbursement issues for that. But let's just think about what we thought what's the risk. What else have we learned that we can do in the home that we didn't think we could?

The patient who is being referred by a primary care doctor to a cardiologist for the evaluation of a cardiac-related complaint. Now, previously, that person would be scheduled for a clinical appointment. They'd come in. They'd see the cardiologist. They get a detailed history, a physical exam. There'd be some decision about what tests they would need to have done. They'd have those tests. And they come back for a follow up visit.

What we've found is that with the information coming in from the referring doctor with a virtual visit with the cardiologist upfront, the testing can be ordered prior to an in-person visit with the cardiologist. The person can have the tests, see the cardiologist on the same day. You've eliminated one trip back and forth to the hospital or we probably eliminated two-- the pretesting visit and the post-testing visit to get the test results.

So all of this makes care more efficient and more effective therefore because you've cut out a lot of the steps. That have not added value to the care, but have just lengthened the care delivery experience and made it more inefficient. That's one example. Pre-op visits, post-op visits are now things that we're realizing we could do quite effectively in the virtual space. So really, the whole area of behavioral health and mental health.

I was talking the other day to one of our child psychiatrist who was saying, look, the virtual visits are actually better because you can have a visit with the child in the family in the home environment. When child and the family come into the office, it's extremely artificial. You don't get to examine what the milieu is like or what the behavior of the child is like in their home setting. You don't get that in the office.

And you're in the Bay Area, the home of tech. And you reference care in the home. In Pediatrics, what we're seeing are these devices that one can put on their phone to help the doctor look for ear infections. I have to tell you, I know if you've seen this Dr. Minor, I saw a toilet the other day where a device can be placed on it. And it can monitor stool on a daily basis for blood-- is potentially a sign of colorectal cancer, can analyze urine or ketones, perhaps early sign of diabetes or UTI. And everyone has a tracker and a sensor. Now there's pajamas even that can tell us our sleep. Is that what the future is do you think?

I think, yes, some element of it for sure. And we have a group here working on a smart mirror as well, given that every morning, most of us are brushing your teeth, and evening too, in front of a mirror. Well--

I'm sure people have said, mirror, mirror on the wall.

There you have it. So all of these digitally enhanced care information about our health, it's being measured in real time and giving us feedback, we've seen it in other sectors and other ways. We've been slow to adopt technology in health and health care in so many respects. Certainly, with the electronic health record, we still use fax machines to transmit information back and forth among--

The health systems is the only group that still uses that.

It's true. It's true. It's absolutely true. So we've got some catching up to do. But I think COVID has taught us that we can do it. COVID has been certainly a national, international crisis of unparalleled proportions, at least in our lifetimes. There are going to be some permanent lessons come out of this that I think is going to make the health of individuals, the health of the world much better. And digitally enhanced care is one of those areas of improvement.

I want to explore that because I did want to ask you, what are the lessons learned? And also ask you, you're at a prestigious healthcare system, yet at the same time, we know that many people have delayed care, have decided not to come for care. In the past year, technology can serve a role in helping to address that. But how do we get people to come back to the healthcare system? We've told them for so long, don't come in. And there are still concerns-- delayed cancer, delayed heart attacks, and in terms of getting the right care. What are the lessons learned? And how do we help address the issue of delayed care as a result of this pandemic?

I think we're going to be working through the consequences of delayed care for the next three, five, even 10 years.

That long?

Certainly. Certainly, we've got a catch up period here. And that's occurring somewhat. But even as the environment becomes more liberal in terms of being able to move around, I think healthcare institutions have always been safe through the pandemic. And we've strived to maintain that trust and that safety for our patients. But there's still people that are skeptical to come in to get preventative care. And the consequences of that sometimes won't be manifested for years to come. But we're going to see it in terms of later diagnoses of colon cancer, breast cancer, a variety of different health-related conditions that the pandemic is going to exacerbate.

And what my hope is that as we learn to use technology more effectively, we've talked about virtual visits, we talked about digitally enabled and digitally enhanced care, that will enable us to catch up at least partially in the future. But there's no question that there are going to be long-term health implications of what we've just been through and are still going through with COVID in our country, and indeed internationally.

Dr. Minor, I want to thank you for providing your insights today in terms of in many ways how does health care look like in the post-pandemic world. Thank you for sharing.

Thank you very much for inviting me. Take care.

And I want to thank you for watching. If you have questions, feel free to drop us a line at [email protected].