On Tech Ethics Podcast – Telehealth for Health Promotion and Disease Prevention

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1. Introduction and Guest Background (00:00:03) Host introduces Danielle Louder, her roles, and the episode’s focus on digital health for health promotion and disease prevention.
2. Danielle’s Work and Organizational Mission (00:01:07) Danielle describes her roles at MCD Global Health and the Northeast Telehealth Resource Center, and their focus on rural health.
3. Defining Digital Health and Its Evolution (00:03:07) Discussion of the evolving definitions of digital health, its broadening scope, and the integration of new technologies like AI.
4. Key Ingredients for Successful Digital Health Initiatives (00:05:05) Explores the importance of people, policies, sustainability, and effective training beyond just the technology.
5. Ethical Considerations in Digital Health (00:08:03) Addresses data privacy, consent, bias, and equitable access, especially in rural and underserved communities.
6. Case Study: School-Based Telebehavioral Health Initiative (00:11:12) Danielle shares a successful example of expanding behavioral health services in rural schools and key factors for its success.
7. Core Challenges in Digital Health Implementation (00:15:20) Summarizes main challenges: policy complexity, digital literacy, connectivity, and the evolving landscape of telehealth regulations.
8. Emerging Issues and Future Trends (00:18:46) Discusses bipartisan support, policy changes, and the shift toward preventive and lifelong digital health care.
9. Recommended Resources for Digital Health (00:22:35) Lists key organizations, toolkits, and websites for further learning and support in digital health and telehealth.
10. Key Takeaway: Advocacy and the Future of Digital Health (00:25:29) Encourages listeners to advocate for digital health adoption and policy improvements to promote well-being and disease prevention.
11. Closing Remarks and Additional Offerings (00:26:39) Host thanks Danielle, promotes related courses and podcasts, and closes the episode.

Daniel Smith: Welcome to On Tech Ethics with CITI Program. I’m going to speak to Danielle Louder, who serves as the co-director of MCD Global Health’s US Programs, and she is also the director of the Northeast Telehealth Resource Center. In these roles, she is responsible for advancing the use of digital health strategies to improve health access and outcomes. In our conversation, we are going to discuss digital health solutions that support health promotion and disease prevention. Before we get started, I want to quickly note that this podcast is for educational purposes only. It is not designed to provide legal advice or legal guidance. You should consult with your organization’s attorneys if you have questions or concerns about the relevant laws and regulations that may be discussed in this podcast. In addition, the views expressed in this podcast are solely those of our guests. And on that note, welcome to the podcast, Danielle.

Danielle Louder: Thank you so much, Daniel. It’s great to be here with you, and thanks to anybody who might be listening out there.

Daniel Smith: So I gave you a very brief introduction, but can you tell us more about yourself and your work at MCD Global Health and the Northeast Telehealth Resource Center?

Danielle Louder: Sure. Yes. I wear a few hats within the organization and I’ve been there for, oh my goodness, going on 20 years now, but as co-director of our US programs for MCD Global Health, I really sort of serve in strengthening health systems and communities here in the US, but we are a global organization and a public health institute based out of Maine, a very rural state and certainly something that is near and dear to our heart and something that we have strongly focused on for many years, both with our digital health initiatives and workforce initiatives, et cetera. But we say as a global health nonprofit public health organization, we kind of look at birth to death and everything in between and really helping to address not only existing health systems, strengthening opportunities, but emerging opportunities within the public health and healthcare spaces as well.

And then as my job as the director of the Northeast Telehealth Resource Center, which is federally funded through HRSA and the Office for Advancement of Telehealth, I’ve been serving in that role for about 12 years now and certainly have been using it in helping folks develop and implement telehealth programs from start to finish since way before it was cool and before the pandemic. But we’ve seen some massive changes in that space, as you might imagine, over the past few years. We work with everyone throughout the Northeast region, which is where we’re technically funded, the six New England states and New York to provide training and technical assistance, resource development to health systems, healthcare providers, policymakers, our colleges and universities who are training tomorrow’s healthcare workforce, everybody that knocks on our door. And certainly during COVID, we started hearing from a lot more and helping a lot more patients and consumers as well.

Daniel Smith: That’s wonderful. Now, just as kind of level setting for our audience, we’re here to talk about digital health. So I was wondering if you could share how you define digital health and then also how that definition has evolved in the past few years, particularly with some of the major advances that we’ve had in technology.

Danielle Louder: Sure. And I love, honestly, as a public health person that today’s conversation is focused on health promotion and disease prevention. We’ve seen some really nice trends in that area, but digital health as a whole, you’ll see a lot of different definitions. Even with the federal government of the United States has different definitions within different agencies, different organizations who have worked in this space, whether you’re in healthcare IT or telehealth, telemedicine was a common term many years ago. There’s a broad scope of definitions. The telehealth resource centers and myself included in that have really always had a very broad definition of what digital health previously really called telehealth, and we’ve seen an emergence of its more being reflected as digital health as a larger scope of tools, services, et cetera, because we have kind of seen from the beginning that it really is… It’s a tool in the toolbox. It’s not this separate thing. It’s not a separate type of service. It’s a tool in the toolbox to help us meet the needs of patients in rural and medically underserved areas in the right place at the right time with the right providers.

So we really see that as including categories such as mobile health, applications, wearables, health information technology, telehealth and telemedicine, and personalized medicine. And also, of course, it’s not sort of the same thing, but now a much more sort of almost ubiquitous use of, I like to call it augmented intelligence versus artificial intelligence within the telehealth space. And I call it augmented intelligence, because again, it’s really a tool that is meant to be utilized by the amazing providers and healthcare professionals to help improve their ability to provide access to care within the space instead of replacing that.

Daniel Smith: I think that provides a really nice overview of the landscape and the technologies that are used within digital health, but aside from the technologies, what are some of the other key ingredients of a successful digital health initiative?

Danielle Louder: Sure. And really, as you have probably seen in your own personal use, whether you use telehealth or applications or just whether it’s for gaming or banking or what have you, the technology is really the easiest part of the equation. Now, it wasn’t three decades ago when we started using telehealth, honestly, in developing systems to address key access issues in rural and medically underserved areas across the globe, frankly, and here in the United States, the technology has become stronger, faster, more functional, more user-friendly, more cost-effective. So it’s really the lighter lift in the equation these days. I would say that the other vital ingredients to a successful digital health initiative within the recipe are really about people and policies. So careful review and planning for program sustainability.

Healthcare should not be about money, but as a nonprofit, we also know no money, no mission. We have to have a sustainable program that we’re able to deliver with the right core of people, clinicians, et cetera, the right tools, the right technology. It has to be billable and reimbursable. So you really have that business plan to make sure that the program is going to be sustainable. And we might talk about this a little bit later, but what you don’t want to do is set up a scenario where you offer this incredible program to enhance access, but it’s not sustainable over time, and then you have to take that service away. That is the very last thing that we want to do.

I would say early involvement in program planning and implementation, workflows that are easy to follow, they can be integrated into existing systems like electronic health records and don’t create additional administrative burden or burden on patients and providers, that’s a key ingredient. Effective training and education communication to ensure that all end-users are aware of the services in the first place. You would be surprised how many people kind of forget that key component and are confident and comfortable in the use of the technology. The last thing that folks, especially busy patients or busy healthcare providers need is another thing added to their plate when it’s not easy to use and it’s creating confusion or does not allow them to meet the same standard of care, which is the golden rule in provision, utilization of digital tools to meet the needs of patients. It has to be the same or often better provided via virtual than it is in person. So really kind of making sure that you have all of those pieces in place as part of your program design and implementation.

Daniel Smith: So with all of those pieces considered and also all of the various technologies out there, I was just wondering if you could also share how you think about the ethical issues like data privacy, consent, bias, and equitable access when deploying these initiatives in rural communities or any communities.

Danielle Louder: Sure. Super important, and I figured that question was coming up giving CITI and your focus. So these are all key considerations in the development and implementation of, I would say, not only successful digital health solutions, but healthcare services as a whole, because we can easily miss those key components in any type of intervention, whether it’s using digital health tools or in-person, and we can create not intentionally, but those inequities and biases in any format, any modality, whether it’s digital, in person, et cetera. So while we saw a massive uptick in telehealth utilization during the COVID-19 pandemic, it’s been utilized by many health systems and providers across the globe for decades.

So the good news with that is that it fortunately means we’ve had time to develop strong systems with respect to data privacy, integration of key requirements like patient consent, like crisis planning into asking for a patient’s address when you connect with them so that if there is a crisis, whether it’s a medical crisis or a mental health crisis, you have their address to be able to send 911 or send help or know where to send them if they should require referrals to additional services or help.

And then also development of AI solutions that help identify and combat bias versus contributing to it. We’re seeing very effective opportunities to do that. So in addition to identifying how digital health solutions can bridge gaps in access for folks in rural and medically underserved areas, we’ve also spent a lot of time thinking about how we can ensure we don’t widen the digital divide for those who need help the most. So this includes designing telehealth solutions alongside those impacted, including rural populations, individuals with intellectual and developmental disabilities, people who speak English as a second language, specific populations like older adults, patients with different physical abilities, et cetera.

And it’s kind of another lens certainly from my public health lens is nothing about us without us, and we truly, firmly believe that, and that’s a lot of the training and technical assistance that we provide as a telehealth resource center is to help people look when they’re developing, planning, implementing and evaluating their program for opportunities for improvement, that they’re really considering all these pieces. Because again, the last thing we want to do is exacerbate inequities. We want to help address them with these digital health solutions.

Daniel Smith: Absolutely. And now bringing all of that together, I was wondering if you can share an example of a successful digital health initiative and what the key factors in that specific case were that contributed to its success.

Danielle Louder: Sure, sure. So this one’s near and dear to my heart. I really would love to share a little bit about our school-based telebehavioral health initiative. It’s really focused on expanding access to behavioral health services for children, students in Maine’s most rural communities, leveraging community health workers as a vital asset and liaison within the school setting. And we actually mirrored this off of a project that we helped develop a roadmap of sorts in the state of Massachusetts, also serving rural schools who were continuously running into the same challenge with respect to not having access to much needed high touch behavioral health services for primarily adolescent, middle school and high school-aged students.

And it was creating a real barrier to learning, right? A lot of missed school time, a lot of parents missing work time because they’ve been asked to come and pick up their children, real negative impacts on educational attainment, all of the things that we are all wanting to address and make sure that our kiddos have the services that they need and can perform well in school and that they’re able to learn throughout the course of their days and years within the school system.

So I would say the key things, what were the factors that contributed to its success, that clear need was identified by the community. We didn’t just come in and say, “Hey, we’ve got a solution to your problem. We’re here to help.” It was a clear problem identified, vetted by that community, and there was collective commitment by partners to address it. So that’s, again, Public Health 101 in how you help address some of the key emerging issues, and there were clear goals understood by everyone and the outcomes were measured and shared on a regular basis so people could sort of track the progress in addressing them. So expanded access to behavioral health services for children, improved medication management where appropriate, decreased and prevented utilization of the emergency department, which is a huge challenge, particularly for rural or healthcare organizations who don’t necessarily have the capacity to take in these kiddos and their caregivers, and sometimes they might have to be boarded for days on end because there wasn’t a bed to move them to, which may be the more appropriate level of care. And then secondarily, we are seeing improved engagement in academic performance.

So all of the sort of stars aligning with providing this additional access. And these kiddos are located in some of Maine’s most rural and medically underserved communities, but we now have access to providers not only in Maine, which sometimes are like four and five hours away from these communities, but in the same state, but we also can tap into providers, specialists, psychiatric nurse practitioners, counselors, et cetera, to enable that high touch care at the right time from many different states. And of course, you know there are legal and regulatory considerations, licensing and credentialing that mean the provider has to be licensed in the state of Maine to provide care to these kiddos, but all of those things are in place and we have ways to do that.

And then from the sustainability perspective, which we talked about earlier, again, it was modeled after a successful program, so we didn’t have to recreate any wheels. We utilized the same toolbox with the job descriptions and the CHW workflows, community health worker workflows, the billing and reimbursement, they were all in place. So we could kind of take this successful model and amp it up and really kind of help expand its reach and impact across the Northeast region.

Ed Butch: I hope you are enjoying this episode of On Tech Ethics. If you’re interested in important and diverse topics, the latest trends in the ever-changing landscape of universities, join me, Ed Butch for CITI Program’s original podcast On Campus. New episodes released monthly. Now back to your episode.

Daniel Smith: I know throughout this conversation you’ve touched on a lot of challenges that programs face when it comes to implementing digital health initiatives, but if you could summarize it in just a few points, what would be the core challenges that you see that programs face that they should be considering so that they can get to the level of success of the example that you just shared?

Danielle Louder: Sure. And I would say where sort of capacity or just the learning curve of designing effective programs, we’ve got a solution for that. Call your telehealth resource center, don’t recreate wheels. So for the workflows, for the technology assessment and choosing your technology, we’ve got you on that. For policies and protocols internal to your organization, we’ve got you on that. So please give us a call, give us a shout. That’s what we’re here for. And like I mentioned earlier, we’re federally funded to provide this training and technical assistance at no cost. So please call us up and we will help you with that. But I would say, and this is unfortunately… I feel like I’ve been saying this for years now and I’m hoping we’re going to get over this hump at some point, but the complex and evolving policy landscape that is applied to telehealth separately from healthcare services continues to be one of the largest issues.

The technical assistance requests that we get, I would say that probably 40% of them are still revolving around the complexity and the diversity in policy between Medicare versus state Medicaid versus private payer policies. If you know one state’s telehealth policy, you know one state’s telehealth policy. So they have differences in the allowable services in whether the patient’s home can be an eligible site to receive telehealth services, the types of providers who are eligible to provide telehealth services. Also, gaps in digital literacy and adequate and affordable connectivity. We have made massive progress with unprecedented infrastructure funding through multiple federal and state opportunities. We have addressed much of the digital divide through broadband expansion, through low earth orbit, satellite solutions, cellular solutions, et cetera. So we’ve really moved the needle on that.

But just because you build it does not mean they will come. So we have to have strong training, resources, et cetera, to make sure everybody’s on the even when it comes to digital and digital health literacy because if somebody doesn’t feel comfortable using the technology, they’re not going to. And again, we don’t want to create those inequities whether somebody doesn’t have devices or they don’t know how to use them, et cetera. So we have over the past few years worked with a lot of different partners, the National Digital Inclusion Alliance and other state-based organizations that are focused on addressing some of that digital divide with respect to digital literacy.

And then I would say not necessarily a challenge, but I’m going to say an opportunity, but boy, AI. Again, I like to call it augmented intelligence because that’s how I believe it could and should be used. It will be used. The genie is out of the bottle. There are so many wonderful use cases, but there are still a lot of questions around how do we make sure that we establish guidelines and shared resources around this incredible tool for use in the healthcare space.

Daniel Smith: And you’ve mentioned a lot of really helpful additional resources, and I want to get back to those in a moment just so we can list them out specifically for our listeners, but before doing so, are there other current or emerging issues that people should be aware of, whether those be forthcoming policy issues or other non-policy related issues just that may affect the telehealth or digital health landscape in general?

Danielle Louder: Well, I’m more of a glass half-full person, so I do think that, and we’ve seen this for many years, telehealth and its use in the healthcare space is strongly supported. It’s a bipartisan issue. There is support for permanently expanding the policies, hopefully to allow the United States to serve as a leader and to really leverage digital health tools. This is sort of my dream. If we can get the policy gaps filled, the digital literacy gaps filled to provide the right care at the right time, that we can truly achieve this seamless transition throughout a person’s healthcare journey, throughout their lifetime, between virtual to in-person, back to virtual, back to in-person for not only acute care needs, but also chronic care management, and why we’re here today, preventive and wellness-type services.

And I see that on the horizon that we are going to see those policy changes made because again, it’s been very much supported on both sides of the aisle, and we have seen states who have vastly expanded their digital health policies to include all provider types, regardless of where you’re located. So the geographic distinctions don’t matter. We’re seeing payment parity for telehealth services, which means they’re paid at the same exact rate as in-person services, which has been a barrier over previous years. So some of the things that need to be changed in federal rule for Medicare have already been changed at the state level. So I think those are going to start to push the global change that we need in permanent telehealth policy, digital health policy.

And I do think we’re also going to see more opportunities, and I don’t think we necessarily touched on this earlier on, but when we talked about health promotion and disease prevention and digital health tools for that, maybe even just five years ago, we were really primarily focused on mHealth applications and wearables, which are utilized by individual patients and consumers, and there’s still a vital tool in the toolbox, but now we’re seeing this great trend toward health systems and providers leveraging all modalities of telehealth, whether that’s sort of asynchronous or the store and forward, secure sharing of images for dermatology and live video, remote patient monitoring, truly as a tool for preventive medicine. So that includes continuous monitoring, early detection of disease, behavior change supports, expanding access to preventive care, including primary and specialty services. So I see this as a trend moving forward that it’s really expanded from this use for dealing with acute care issues to a tool that’s truly going to be utilized for kind of that seamless lifelong healthcare journey where preventive care is a big part of how we’re using these digital health tools.

Daniel Smith: So back to the additional resources, I know you’ve mentioned the regional telehealth resource centers and others. Can you just list out some of the additional resources that you think would be great starting places for our listeners to learn more about the issues that we’ve discussed today or explore things in further detail?

Danielle Louder: Sure, sure. And there are so many. So again, if you’re looking to sort of dig into the weeds on any particular area, please reach out to us. Chances are either we know somebody here in our own region or we connect regularly with all of the other telehealth resource centers, so if we don’t have something or know something, we can connect you with them and they can easily connect you. But I would also say all of the telehealth resources centers are part of the National Consortium of Telehealth Resource Centers and we have a website for that, which would help you sort of get directly connected with all the other TRCs. I would say there’s the Federal Health Resources and Services Administration and hhstelehealth.gov is a wonderful resource, which lots of national partners regularly post resources to that website.

The Center for Connected Health Policy is our national policy. I’m kind of teeing it up here for people to advocate for this policy change that we talked about a little bit earlier that has continued to be a challenge. But CCHP, our colleagues there, create wonderful resources so that you can better understand your unique telehealth policy in your state and what’s trending in some of the other states and even what Congress is currently looking at for bills and laws and state-specific what they’re looking at for bills in their current legislative sessions. The other national telehealth resource center is the Telehealth Technical Assistance Centers or TTAC. So it’s the technology, they’re the gurus on all things AI, if you want to look at different stethoscopes, Bluetooth stethoscopes, they’ve got a whole toolkit to look through the weeds on different types of technology peripherals in the telehealth space, et cetera.

The National Digital Inclusion and Alliance and the National Digital Equity Center are great resources, kind of one-stop shops for looking at opportunities to address some of that digital literacy challenges within your communities. We have toolkits on our telehealth classroom, which is on the NETRC website, the Northeast Telehealth Resource Centered website, that helps you from start to finish. How do you develop and implement a telehealth access point in a non-medical location like libraries, et cetera, for communities that are truly so remote that there’s maybe not a healthcare facility for many, many miles away. So we’ve been doing a lot of work in that space too, to help establish telehealth access points in very hyper-rural areas as well. So those are just a few. Call us up if you have a specific area that you’d like us to look into for you.

Daniel Smith: Those are all very helpful, and I’ll be sure to include links to them in our show notes so that our listeners can check them out. So as my final question today, to close us out, it’s just if you could leave our listeners with one key takeaway about the role of digital health in promoting wellbeing and preventing disease, what would it be?

Danielle Louder: Yeah, I would say be an advocate for yourself, whether you’re comfortable with using digital health tools, do not be afraid to push for your healthcare systems and providers to leverage those tools in order to help you get the right care at the right time and the right place. Your voice can make a huge impact in achieving the type of seamless integration and improvements in health access and outcomes that we’ve talked about throughout this conversation, but it does require closing some of those policy gaps, investment in digital literacy and addressing broadband inequities. If you still live in an area where it’s difficult for you to either access the internet or do it affordably, I would strongly encourage folks to use your voice to promote the changes and the realization that we can accomplish together and using digital health tools to help improve our health and wellbeing.

Daniel Smith: And that’s a wonderful place to leave our conversation for today. So thank you again, Danielle.

Danielle Louder: Yeah, thank you so much for having me.

Daniel Smith: If you enjoyed today’s conversation, I encourage you to check out CITA Program’s other podcasts, courses, and webinars. As technology evolves, so does the need for professionals who understand the ethical responsibilities of its development and use. CITI Program offers ethics focused, self-paced courses on telehealth, digital health, AI, cybersecurity, and more. These courses will help you enhance your skills, deepen your expertise, and lead with integrity. If you’re not currently affiliated with a subscribing organization, you can sign up as an independent learner. Check out the link in this episode’s description to learn more. And I just want to give a last special thanks to our line producer, Evelyn Fornell, and production and distribution support provided by Raymond Longaray and Megan Stuart, and with that, I look forward to bringing you all more conversations on all things tech ethics.