March 2023 - Towards Equity in Telehealth Challenges and Opportunities (Bisan Salhi, MD)

- Welcome everybody on this fine March, Tuesday afternoon. We are lucky here at this section to have Dr. Salhi come and present to us, about sort of basically telehealth equity and some of the populations that we may have certain assumptions about and that they may or may not be able to engage with telehealth, but yet I think she's gonna challenge some of our assumptions. So, I'm gonna pass the microphone over to her, let her introduce herself. She's also at a new institution now and so I'll let her introduce herself and present and we'll have the Q and A afterwards like we've had before. So Dr. Salhi, the floor is yours.

- Thank you, Dr. Hayden, and hi to everybody this afternoon. I am Dr. Bisan Salhi. I am an associate professor of emergency medicine and assistant dean for student affairs and DEI newly at Drexel University. So, I'm in the Philadelphia area. Just to give you a little bit of background, in addition to being an emergency physician. I actually got my PhD in medical anthropology and I did my dissertation research actually on homeless super utilizers in the emergency department at Grady Memorial Hospital where I was at the time at Emory. And so that really informs I think a lot of my, just thinking around this topic and a lot of sort of my personal passions and kind of populations of interest. And so, I look forward to talking to you more about that and I'm going to just share my screen, so that we can go ahead and get started. Can everybody see that?

- [Emily] Yeah, we can, yep.

- Okay. Well, thank you all for having me. In addition to kind of the introduction, I think we should probably just get a couple of things out of the way. The first is that I do not have any conflicts of interest to disclose, but I should also just disclose to you that I am what I would call myself as self-identified kind of digital immigrant. And so I am not a person who is particularly tech savvy and still kind of a nostalgic for a world without internet. And so I tell you that for two reasons. The first is that you bear with me, should any technical issues arise. But also, really as a testimonial that if I'm sort of a person who is sitting here talking to you about the promise of telehealth in vulnerable populations, I really think that there's something very much there and that you're onto something. And that I'm just really excited about the potential that telemedicine has to kind of expand access to all populations and really help us rethink the ways that we deliver care to help us get closer to our goals of health equity. And so I just really, what I'm hoping to kind of do today is sort of talk in a very nuanced way about, not just about health equity but telehealth equity as well, and just kind of thinking about kind of the nuances of digital connectivity as well and kind of their promises. And also just some challenges that we should be thinking about as we kind of go forward and expand the EM footprint in telehealth. And I think it's pretty obvious, I certainly don't have to tell any of you or anybody who has lived on this planet in the last few years that digital connectivity isn't really just a luxury, but it's a necessity in our world. And I think that this is even more true for people who kind of live at the margins of our society and have really existed at the margins of our healthcare system for quite some time. And I think, similarly, we all know that internet connectivity, despite all of its advantages and so many other essential goods and services in our society is not evenly distributed. That is an obvious thing that most people have usually described as the digital divide that people use to talk about whether or not populations have had access to hardware and specifically computers and internet access. I am not necessarily a proponent of this binary description of internet haves and have nots. And I think that that's just because, as we are talking about technology and internet connectivity just even in the past few years, that just what that entails has become much more complex and nuanced, and includes things like, are we talking about smartphones, are we talking about tablets, are we talking about internet? And what exactly do we mean by access? And I think what's really important is that our nomenclature also evolves to beyond this binary divide to think about, whether or not a population has access to hardware, to the internet, to kind of viable internet connection speeds, and all of the skills that they also have to be able to kind of access these tools. To reflect that, then I think it's much more accurate to talk about digital equity, which is a framework that I think has been or that's been getting a lot more traction. Just so that we're on the same page, digital equity is a condition in which all individuals and communities have the information technology capacity in order to participate fully in all aspects of society. Pretty closely related term is digital inclusion, which is, just thinks about the ways in which we can kind of remedy deficits in digital equity. So in other words, if digital equity is the goal that we're working towards, digital inclusion is the work that we and our partners do in order to reach that goal. And so, the ideas of certainly equity and inclusion, are not new in emergency medicine. And so, I think we already sort of have some of the framework and the language to be thinking about these things, and there's really an opportunity to be including and extending that work into telehealth. Also, think about this, I think, it's important to state that to achieve digital equity in the context of healthcare, it's important to commit to think about social stratification and research design, and methodology and knowledge translation and outcome measures. And I talk about social stratification, because it includes analyses of race, class, ethnicity, gender, age, all these things that, including like geographic location, disability, incarceration, that really can affect the ways that people engage with telehealth specifically. And I wanna kind of stress here that this is not really just an ideological commitment, but it's a process that is very clearly, can be evident in the kind of questions we ask, the people who we engage with, who we take seriously and ultimately sort of the products and services that we produce. This is obviously not at all a small task, it's much easier said than done, but I think it's also important to realize that when we work sort of towards digital health equity, like all other work in equity and inclusion, it isn't just difficult, it's complicated and it priors us to think outside the box, about how digital inequities can sometimes mirror and sometimes diverge from equities we're familiar with. And so, of course, digital inequities can't be divorced from broader social and historical realities, but it's important that we think about how the digital world doesn't always neatly map onto the rest of the world as we know it. And so, to think about this, again, I think that it's important to think to abandon ideas of people either being technologically rich or technologically poor, and to recognize that the contours of the digital divide, are kind of constantly changing and increasingly complex. So, let's kind of think about this just for a second. So, if we look at kind of the Pew Research Institute, they have sort of done studies on online and engagement and access to internet. And if we look at sort of the graph on the left, we can see that that number of who is offline, who does not have access to internet, that number has decreased significantly since the turn of the century. And so like, really that's just a very small number of us that do not have access. And if we look at actually like the offline population by demographic, we see that the starkest inequalities, play out along educational, income and age lines. And so we see, for example, that there is not much of an inequity by gender. There's a little bit less of an inequity by race, but obviously, there's a very stark inequity by age, by income, and a little bit more also, based on spatial divide. And so, of course, this is not to kind of say that these categories themselves kind of distinguished from race and other inequities as we know them. But I think that there's a lot of nuances that kind of need to be taken into account. And so again, if we kind of look a little bit more, then one of the things is kind of the rural urban divide, just something to sort of think about and we'll talk a little bit more about later as one of the important axes of digital inequities. And we see here that despite making significant gains, since about 2000, rural Americans are consistently still behind urbanites and suburbanites in digital access, despite kind of those significant gains. So, we get some important insights in looking at these numbers, but I would really argue that they're not enough for us to fully understand the people that are engaging with these tools and the worlds that they inhabit. And so, instead of just thinking about how many people are accessing the internet, what health services can we provide and to whom, I think, it's important to think about why and how people are engaging with technology and how this reflects their priorities and personal and broader social circumstances. And so, as I mentioned earlier, like my personal and academic interest is in the subject of homelessness, and I'm obviously biased, but I think that I would make a pretty strong case in arguing that we have a lot to learn from the ways in which people struggling with homelessness, kind of use the internet and engage with technology to help in their daily lives. And I think it's important to kind of call out a pretty broad misconception, amongst not just emergency physicians but frankly, everybody, that people experiencing homelessness are either not willing or able to be digitally connected. But I put this study up by Rose and colleagues from UCLA, which showed at the time that 94% of the homeless adults in their study had a cell phone and more than half of them used it every day. Similar studies by Dr. Raven and colleagues in San Francisco found that participants who regained housing were significantly more likely to have mobile phones, than they're digitally unconnected counterparts. And I think that this underscores the part that nearly everything around us is online these days. And a cell phone isn't just necessary for somebody to kind of escape the perils of homelessness, but also, just to get by day-to-day, while experiencing homelessness. And so that's why there's a lot of other studies of both homeless youth and adults that have shown that they have access to cell phones, that they use them regularly and in goal-oriented ways that focus on health, housing, employment, and subsistence resources. And so to give you kind of an example, some of the things that they might be using a cell phone for regularly are to keep appointments with lawyers, because they might have carceral concerns or encounters with the criminal justice system or to get to job interviews or to navigate public transportation. And so, in these cases, cell phone and internet do for people experiencing homelessness what they do for all of us. So, they just help us store information, organize our time, and there's really real opportunities for us in healthcare to add into those services that they are really accessing every day. So, that access to mobile and cell phone service, is not just a theoretical one. People have already leveraged mobile phones to help homeless patients, medication adherence, appointment attendance. And so in this particular study done in Virginia, 89% of homeless patients who were surveyed had a cell phone and about two-thirds of them were interested in reminders to refill their medications, to take their medications or to attend appointments. Similarly, other studies have found that cell phone communications, so like text messaging, pillbox apps, automated calls, improved medication adherence and appointment attendance in homeless patients, including those who suffered from co-occurring substance use and psychiatric disorders. And so these are not, I would really challenge us to sort of not be thinking about these as exclusionary for engagement with telehealth, but there's been a lot of kind of documented successes with these populations and engaging in telehealth. Again, sort of I think that these apps are not also just useful for patients to carry out treatment plans. But I also think that they're important for us to sort of think about whether or not, treatment plans are successful without, by gathering really reliable objective data, rather than relying on our subjective or stereotypical assessments of who's reliable, who's honest and who's gonna do what, which are really nothing more than problematic reflections of our own biases, but rather than any accurate judgements of who people are. And it just stop for a second and to say that despite my excitement, I don't want to imply that kind of internet or cell phone access is somehow a panacea for the difficulties of homelessness or any other social suffering. People experiencing homelessness are still vulnerable to device stuff. Insufficient or slow data services, relying on public internet, charging stations, and even if they have cell phones and they have access to it, their service may be cut off for prolonged periods and their numbers may change. And I think that any kind of form of technology or innovation, no matter how benevolent, we should also be thinking about unforeseen consequences and harms with rolling out these types of technologies. And I'm gonna talk a little bit more about that later, but I think we should keep in mind that really any work with disenfranchised populations, has an inherent tension between the need to gather accurate, reliable objective data on one hand and also making sure that that data is not leveraged in discriminatory ways against the people who are actually supplying it. And so these are certainly not things that I purport to have the answers to, but I definitely think that they should always be in the backs of our minds as we are delivering and creating healthcare services. So, one of the things also that we should be thinking about is what are perceived versus actual barriers or challenges for telehealth engagement? And so, to give you an example of what I mean, I've sort of spoken to a lot of emergency physicians and a lot of other primary care physicians and other people about engaging disenfranchised populations in telehealth to increase access. And there's always sort of a few recurring themes that come up. The first is somehow that people like I mentioned, people would either be unwilling or unable to engage in these services, and I hope that I've given you some evidence to the contrary thus far. The other, I think, is that somehow expanding telehealth access, would open the floodgates to either inappropriate visits or overused or depletion of healthcare resources. And I think that, I would like to sort of call out that people who are materially deprived, who are experiencing homelessness, who have trouble with substance use or any other difficulty, it is inaccurate to just blanket characterize them as irrational or people that are not acting in their best interest at all times, and people that cannot somehow engage in the services that we offer. I think, sometimes their interests or their priorities don't align with ours, but that does not make them irrational. And I think that it's important to also call out the notion that expanding care to these populations is somehow not in our best interest. 'Cause I would argue that that is actually the cornerstone of our specialty. Like, just like airway and resuscitation, that caring for the most vulnerable people is a cornerstone of what makes emergency medicine what it is. I think the other thing that really came up is that telemedicine would somehow be a substandard way of evaluating patients and that there was some concerns that the expansion of telehealth would mirror the stigmas of the rest of our healthcare system and would ultimately worsen health disparities. And I think we have some experience already to the contrary from other contexts to think about how we can engage and to think about some of the pearls and pitfalls of this process. And so, I really like to show this slide at the time of the COVID lockdowns, because I think if it was a real opportunity for proof of concept for telehealth among people experiencing homelessness. And so, if we're looking at this, the National Healthcare for the Homeless Council reported that expanding telehealth capacity. And so if we see here, like right at the time of the COVID lockdowns, and specifically, expanding audio-only visits in the healthcare for the homeless healthcare centers, made a really important impact on the access to healthcare services. And so we see like, in March and April, when there were widespread lockdowns and centers kind of really quickly had to shift to telehealth, a lot of sites across the country showed a decreased in missed appointments, and you see that some of the centers reported much more dramatic decline in others. But I also think that these centers serve lots of patients and so I think that even a one or two percentage change in the no-show rate can really mean that there are potentially dozens of people if not more, that are actually receiving care that they would not have otherwise received. In the same study, also it was noted that it wasn't just about expanding access but in terms of numbers, but also the way that people were accessing care and patients' comfort levels. And so for example, this healthcare provider from, and by provider, I actually mean to use that word intentionally, they think they specify the licensure of this particular quote, but they said that, "They've noticed that this particular person "in Middletown, Connecticut said "that they've noticed that patients are more honest. "They aren't fearful that we're going "to report their drinking "or that they didn't take their meds "or that they stayed at someone's house. "They're being more candid, "and that's a big benefit to providing good care." And it's really that connection and quality of care that we're all, I think, whether or not we're interested in telehealth or not, striving for when we aim to kind of improve access for these patients. It's important again to realize that rapid shift in telehealth that happened in March of April of 2020, did not just sort of occur out of thin air. Years before the pandemic began, health centers across the US and across the world really were actively engaged in providing behavioral health to people experiencing homelessness and people who were otherwise marginalized, excuse me, using telehealth platforms. And there's a number of ways they did this. And so for example, they've used existing mobile health units, setting up kiosks at local shelters and delivering healthcare using shelter space and internet resources. Almost uniformly, the data that comes out of these experiences shows that patients really have really strong buy-in and that also they're really willing and enthusiastic to engage in these services for reasons that we're obvious to all of us here. So, telehealth can eliminate some existing barriers, such as transportation, which I'll talk about in a second, a lack of paid sick leave, childcare needs and can really be delivered in a context that's comfortable and convenient for people and can really foster coordination between healthcare and homeless service provider in a way that is convenient and beneficial and really not possible in other aspects, in other healthcare spaces. And so again, that's not to say that the process was without its difficulties, but the difficulties really came from structural difficulties, like navigating connectivity issues, finding funds and resources for labor-intensive startups, and that sometimes, patients would kind of leave the shelter to go elsewhere. So, to live with family members and would not necessarily be able to participate in these programs long-term. I think, even with these challenges, there's still great potential for partnering health systems and community partners to make communication more seamless for patients. And so telehealth can still be integrated into many strategic initiatives within the healthcare system to expand their reach to patients who would normally either be excluded or alienated by the traditional structure of the healthcare system. And so, for example, in this study that's much more recent, the authors described their experiences, setting up telemental health services within homeless shelters and partnering with integrated care teams to meet patients where they are, and to develop models of care that are timely and cost-effective. And certainly, there is opportunities again to kind of expand telemedicine partnerships with homeless service providers, senior care communities, carceral facilities, EMS units, and other community partners to expand their reach and care. I obviously know that that's a very tall order that requires balancing healthcare system needs and priorities, ED initiatives, finances and reimbursements and the capacity and priorities of community partners, not to kind of mention the patients themselves. Which is not to say that it shouldn't be done, but also to say that I recognize that it requires a careful balance, between experience and innovation and ongoing assessment and reassessments of all stakeholder experiences, even after programs are up and running. These difficulties though should not detract from the obvious benefits of telemedicine and its ability to bridge the traditional physical barriers of healthcare. So, I think telemedicine, can help overcome innumerable barriers including access to specialty care, childcare transportation, time off work. I know that I don't have to tell you this, this is something that I experienced both as a patient and in my own clinical experience, but I wanna think about in a little bit more detail, just one of these aspects which I think a lot of our patients struggle with, whether experiencing homelessness or not, which is transportation. I think that that's actually one of the most promising barriers that could be overcome by utilization of telehealth. And so, you may be surprised to see how many households in the United States do not have access to a vehicle, particularly, in rural communities. And I wanna stop here and say that by access, we don't just mean ownership, but actually the ability to literally access a vehicle, through either a friend or a family member in your household or not. And so, I think when we think about it that way, it is still a pretty striking number of people that actually don't have access to transportation. And there is a plethora of evidence that walking or using public transportation or not having access to a vehicle, is a significant independent predictor of not receiving healthcare. So, patients who don't have access to private transportation are significantly more likely to delay receiving healthcare. They are also much more likely, in the pediatric populations, parents who don't have access to vehicle, are much more likely to leave prescriptions for their children unfilled. And so obviously, this is something that affects age groups across the spectrum and really has tremendous potential that if we can kind of overcome that barrier, that it can really bridge a significant gap in some of our healthcare disparities and access to healthcare sort of more generally. I want to then circle back now to this idea of unintended or unanticipated consequences which again, I think are really important to think about in any endeavor or project rollout. And particularly, important here, given the rapid adaptation and embrace of telemedicine, especially, in emergency medicine. I wanna take, for example, this 2007 study, so pretty dated, but was actually a pretty robust study, done on a telemedicine project that linked PCPs in Northern Italy with specialists at a tertiary care center to improve access and specialty care. And as expected, patients did indeed have a harder, I'm sorry, did have an easier time, accessing specialists and particularly for people with complex problems. So in this study, people who had really complicated heart failure, I was one of the conditions that they cited. And so, what the author also found was that the tertiary care center, as they established closer relationships with patients, that this sort of led to a progressive bypass of primary care givers as the first point of contact for their patients. And the PCPs in this study were kind of happy to actually relinquish and delegate their patient's care to trustworthy specialists 'cause they were stretched to their limit, and also really trusted the complex care of their patients to the specialists. But at the same time, they felt dis-empowered by this new arrangement and the flow of decision making. And the authors, I think, kind of astutely observed that this collaboration also triggered a shift in the geography of healthcare relationships, and had the potential to trigger financial disinvestment in the local healthcare infrastructure and a consolidation of money in larger healthcare centers. And so, I recognize that this is a study from Italy and it is a study from 2007, but I think that there are, if we think about it, still residences in the rural urban divide and a lot of the things that have been happening in the United States as well. And so I just sort of bring it up as an important point of information to think about as we're developing these platforms and services and realizing that short-term effects may be very different, than long-term effects as well. The other thing I wanna kind of point out is that in addition to diffusing healthcare relationships, it's a really important to think, about the potential for telehealth. And a lot of the ways actually, this is not specific to telehealth, but to my mind though, a lot of the ways in which we're sort of shifting to deliver healthcare to patients is that we have very much the potential to shift a lot of burdens and labor onto families and patients themselves. And so, as an example, I would encourage you to read this still very timely article from 2016 where the author describes how our very behemoth healthcare bureaucracy, really puts the onus on patients to coordinate their own care. So, from being liaisons with their insurance companies, scheduling multiple appointments, figuring out drug pricing, I certainly don't have to tell you, you probably all have personal and professional experiences with this that are quite maddening and we've all witnessed how it really leads to either ED visits or adverse outcomes. And I would also argue that the shift in that labor to people who don't have the capacity to take it on either through social support or finances, can have even much more detrimental effects than it would on people who have access to a lot of resources. And so the other thing and I just wanna kind of leave you with this is to say that it's important to keep in mind and the something that I wonder about is if the adoption of telehealth, would really accelerate our system's many tendencies to assign the patients onto themselves. And again, to really think about whether what is convenient for some people may be completely impossible or undoable for others. And particularly, those with the most complex needs and the fewest resources among us. So taken together, I just wanna just say as we close that all of these examples, I think, tell us that what we should be thinking about, how to use patients' experiences and priorities to inform the overall platforms and products and services that we produce and the way that we engage with patients to provide either episodic or longitudinal care. And so, everybody really wants to rush to build something and to help patients directly. But I think to do that properly in the most effective way, we really have to think about not just the data we gather just in terms of like just, but also just making sure that it's accurate, that it's nuanced and that it really addresses not just our priorities but also the people who are actually using the products that we produce. And so, it's really important, I think, that we innovate with people, rather than for them across the race, income, gender, like across all of the spectrum of social stratification in our society. And I think if we take this as a guiding principle, then telehealth and emergency medicine, really has the potential to reach people in really intentional and meaningful ways. And so, I will kind of just leave it there for discussion. I just wanna say thank you all and I really again appreciate the invitation and all of your engagement. So, thank you very much.

- Amazing. Thank you back, right? Thank you right back there. And I'm gonna open this up for questions too, but just one of the things I was thinking about listening to what you're saying, you've been steeped in with your thesis, with your role, with your anthropologic background, what would you think, like, at that very end you said, trying to innovate with people rather than for people. What do you think might be, and you've tried to touch on some of these, but maybe some specific misconceptions when we're trying to develop these. If we were channeling one of the patients that you've interviewed in the past, what might be a surprising thing that we just never thought or an assumption we have, when we're maybe developing like an ED avoidance where they wouldn't have to come into the ED for their visit? We might be able to do like a virtual urgent care visiting. Is there something that you can think that they might say that we are totally wrong about?

- Oh, there's probably many things I can think of. I think one of the things that I think I really surprised me and that a lot of people, I think, when we kind of think about people who are experiencing homelessness, often we have a trope in our minds of kind of a lone urban nomad of particularly, like somebody who is isolated from social networks, be they other people experiencing homelessness, if they don't have friends, they don't have family. And I think that that could not be farther from the truth. I think that what they are devoid of is probably social networks that we recognize as important or meaningful, but that does not mean that they're not important or meaningful to them. I probably have given like a whole talk about that actually on its own. But I think that, we often I think have a bias of particularly engaging homeless people as if they are the only ones carrying out their care and not asking what resources do you have available, who is there to support you? And again, this is not to sort of imply that there's some kind of panacea of like, that there's this great, there's a lot of sort of social difficulties that come with being materially deprived and impoverished. But I also think that we often make assumptions about what people's lives are like, what their priorities are. And we don't often stop to ask, what's actually important to you right now? Like, what is it that I can sort of help you get through? Who's important in your life? Who can help you? And I think we often sort of rely on in my practice or like thinking about, "Well, we can help like social services help you," without sort of thinking about their points of contact. And we don't necessarily leverage the resources that they have in mind. And this doesn't directly also answer your question, but I think one of the things that we often forget is how much physical and mental wherewithal it takes to survive on a day-to-day basis, while experiencing homelessness. And I think often we don't give people enough credit for being, in some ways, like really able to actually carry out, really important plans and really be able to sort of function on a much higher level. I think, we're pretty dismissive of them unfortunately, without sort of recognizing that their experiences are important, even if they don't necessarily align with our priorities in that particular moment. So, that's a very long-winded answer and I hope it answered some of your questions, but I think those were kind of my big takeaways, when I was doing my research as I've talked to people.

- Thank you. That's great. Open these up for others who have questions, Dr. Salhi.

- Dr. Salhi, that was awesome. Thanks so much for the talk. You mentioned a couple of really interesting things, one of which was sort of audio-only visits. I live in New York City, New York Allen Hospital, built sort of into their virtual platform, a lot of intention around having it be launched straight out of a browser, have it be like lightweight. Are there other things like that that we should keep sort of in our digital toolbox to build sort of equity into the core of these products as we make them?

- Do you mean, can you just tell me a little bit more, about the product a little bit, just being like launched out of the, I just wanna make sure I'm understanding you correctly.

- Yeah, a lot of our virtual products, at least at my system, live like behind apps that require logins and MyChart accounts and there are a lot of barriers just from that perspective. And that doesn't necessarily add cost, but it might add processing power or something like that, and I wonder if there's more best practices out there or literature out there to show like, what makes digital products like this the most accessible to a vulnerable population?

- Yeah, so one of the things for example, there's in a prior iteration of this talk, I actually gave a sample from, it was a, I forget what their federal designation is, but like there, it was in like kind of the DC area, it was a clinic called Unity Health Care. And one of the things that they found and I think a lot of people have found is that once you sort of start hiding stuff, like there's kind of a trade off between security and accessibility particularly in these populations. And so one of the things that they, yes, it was a federally qualified healthcare center. Thank you. So, one of the things that they found was that if you could actually have like a bypass such that if somebody couldn't remember their password, that you could just send them a text to be able to actually that, to be able to actually like access a video visit to kind of bypass a lot of those like a aspects of it. So, that's like one, I think, like pretty clear example of, and I think they tracked the data of when they found it, when they started actually implementing that, like their accessibility really went through the roof of just kind of figuring out how to just send those links directly to patients.

- Got it, makes sense. Thanks.

- [Bisan] Yeah.

- I have a question actually for one of our other participants here, 'cause I see your video on too, Dr. Alvin. From your perspective, from emergency medicine but also from like the vendor side, from Epic side. I'm curious with some of the access and equity issues, I know as Dr. Kenhart said, "The access to MyChart and some other pieces in that." Have there been initiatives at all that have been trying to work on some of this, especially, with such a rightfully so focus on the social determinants of health and people's access for healthcare?

- Absolutely. And I think a lot of what Bisan talked about and Rishi mentioned as well, echoes in where we need to look at it. For us at Epic, it's what our customers tell us that they need to do. And as they increasingly recognize the importance that having an equity-focused effort and what the different tools are that they do can help, that pushes us to provide tools to do that that they can use. Not everybody uses our, for example, our video client, but that's okay. You can use whatever you want. But the principles and Rishi just hit on it, you don't have an app that someone needs to download. It needs to be a lightweight browser launched on the real time. You need to do audio-only when it can. We're doing two-way text messaging, because exactly as touched on that increases your ability to reach people who are using a variety of levels of technology and that can be really important. One of the things that sort of echoed in my head as well is we put out the dashboards for success. You want your telehealth calls to have a certain success rate, and it's hard to get that to, you can't get it to 100, but monitoring and keeping that in mind and then also looking at it across the different populations that you care for becomes an important aspect. You mentioned the HCH, Health Care for the Homeless. I quick look that their website was interesting to note that a smattering of our customers have sites that are HCH certified or part of that, like Harris County in Texas, Waco in Texas, Southern Illinois, and I couldn't identify all of them but a few of them certainly are doing that. It's interesting, there's probably learnings in terms of from a whatever vendor you're on, what have your colleagues who use those tools already figured out what are the things they've worked on, what are their struggles in that cross pollination to recognize where are the opportunities and tips and tricks and other things that you can learn from your peers and colleagues out there who are doing this at every little local level that it takes to do this. So, I don't know if that helps, Emily, but certainly, on our radar, it's everything that from the social standpoint, you mentioned transportation as well, all those things, no panacea but you gotta chip away at all those little things to make a difference with this sort of stuff.

- Yeah, I mean, I think that healthcare can't work if we can't access it. And so if we can just kind of get to a point where we're having some access, I think, that that is a win in and of itself if we actually kind of leverage that. And I've seen studies, I'm certainly not a global health person, but where a lot of these technologies have been used, kind of to leverage care in Bangladesh. And so I think that it's not just about learning, I mean, it's about sort of thinking broadly, about lessons learned even before the pandemic. This is not new. I think, a lot of us are sort of thinking like since 2020 and how can we upstart rapidly? But there's a lot of lessons to be learned, not just from what people have done in Texas and in California, but also like really across the world that these are things that people have been thinking about for a long time.

- Yeah, the internationals are fascinating, 'cause often their healthcare is structured so differently, they automatically think about this differently than we do here. And so, it's sort of burned into their approach. Finland's a great example. The whole social care element is built right in, it's not seen as a separate thing. It's part of healthcare and that changes their whole outlook and their whole approach to the way they deliver things.

- Dr. Ernst, I saw that you unmuted. Did you have a question?

- [David] Actually, Emily, more of an observation, I think.

- [Emily] Yeah.

- [David] I'm thinking about a lot of what's been discussed, and a lot of the discussion seems to be trying to really get the technology in actually the hands of the individual patient. And if you think about a good portion of the people who are in that situation have somewhere that they have to go for resources to survive, food, shelter, on least a somewhat regular basis. Whether it be a community shelter, a semi-government, what have you. And if I were setting up a program like that in my regional area, I would think more about getting to those places, getting the technology to those places and available to them so that when the people come in, it's readily available at that time, because it would seem to me that the hardships involved in living on the street, would put at risk any technology that that person is gonna have available, whether it be through breakage, theft lost, mental illness lost, whatever it may be. Not meaning any disparaging comment toward the person who is handling the technology, it's more the living conditions that they're forced to live under and the crime and violence and the hardship and the weather, and all of the other things that they lived through, the possibility of an individual having technology with them to utilize in this manner in all times is in my mind pretty remote. So, why not put it in a safe location where they will be at least on a semi-frequent, if not daily basis, so that they can then just go tap into it when it's necessary? Or have someone with that technology that identifies the need for them to tap into the equipment even more important.

- I mean, I think one of the things that you point at and particularly was sort of setting up services in kind of like community service providers, is an important one because it gives the opportunity also to not just provide care for one person, but to also provide stable care for a group of people as they may or may not cycle in and out of homelessness. And then one of the things I would just add to that as well is that it's important to also realize that a lot of the infrastructure of a lot of these shelters or homeless service providers is in itself lacking. Because often what people will donate is, I'm sorry, I don't know if you can hear it. Like, there's a lot of background noise here, okay, good. A lot of what people will donate when they're thinking about what do people experiencing homelessness need, is like toiletries and food. And of course, these are things that are important, but we also should think, one of the things that we would like that, this may be answers your question as well, Dr. Hayden, from earlier, is one of the things that people often would ask for when you ask them what they needed was access to transportation. What they needed was were train cards and it's not cheap to ride the train, it's not cheap to get around, it's not easy to get around in the United States if you don't have a car, maybe in some places like New York or Boston, but most other places, that's not the case. And so one of the things also we should be thinking about as we're doing outreach is also investing this internet infrastructure, because just because the place is in the middle of Atlanta, does not necessarily mean it has the internet or the hardware, even if it has the capacity to do it, to actually be able to really host a lot of these services even if they would be really widely used and super accessible. And so I think that it's important to also have a mindset shift in that these are also things in addition to soap and food that people experiencing homelessness genuinely need and would benefit from. So, just kind of add to your observation as well.

- Great conversation here. What other questions people have or comments or maybe examples that you've seen that have challenged our assumptions and actually have been successful or realized unintended consequences but have mitigated them with changes?

- I would actually like point, there was actually in, and it was in Silicon Valley, but there was a local nonprofit that actually made it its goal to upgrade all of the internet and all of the access to all of the homeless shelters that was there. And I think it would be really, I forget, I would have to actually look up the name of the nonprofit, but they invested millions in just that and just kind of expanding internet and online resources in homeless shelters and homeless service providers. I'd really love to see something like that, replicated outside of kind of San Francisco and Silicon Valley.

- We've Silicon Valley Bank and all that stuff right now too, so.

- Oh, yeah.

- I don't think they were the ones, they weren't nonprofit. Dr. Olson, I saw you come on view and-

- And popped on mute. This is a great talk and it's so timely for us. We're struggling with all of this. Our providers are the ones that end up doing all the legwork for the patient. It's really hard, and it then it ends up coming down to, 'cause we have a program where we just simply want to discharge the patient from the ED and let them do a follow up with us. And just to see how they're doing and just to get them on myConnect and make sure that they have their Connect account, has been really challenging. We do have the text, what is it called? Text to connect. It's a text message where we can send it, but they still need much more handholding and it boils down to the provider and that's not good, because the provider needs to be doing other things. So, we're definitely struggling with this. So, I appreciated a lot of the things that you said and just appreciate that you care so much about this population because I don't know that, it goes under the radar for a lot of folks and so it's coming down to our providers.

- Yeah, it very much comes down and I think it very much sort of comes down to that. I think that's a really important observation. And I think one of the other things that kind of people don't, I think, they may be implicitly recognized but don't say out loud is that when you are working with particularly vulnerable populations and I'm speaking about homelessness, because that's what I know best, but I think that's probably true for other groups as well, is that it isn't part of the labor and part of the job, isn't actually just delivering healthcare as in like, "Here's your prescription, go fill it." It is also genuinely providing a lot of of support and really kind of making that connection with people, because otherwise whatever you do is not gonna be effective. And there's, I think, a significant amount of emotional labor that is kind of built into this work and not necessarily always recognized or certainly never properly compensated. And so I think it's just important to think about that.

- That's right. And the provider is the one, as you said, who feels the most invested in this. Like, I wanna make sure that tomorrow you're okay. They're the one that's the closest to the goal with the patient and so they're the one that's saying, "Give me your cell phone."

- Yeah, I mean.

- [Olson] Downloading things, It's crazy.

- So, I've done like a couple of studies with actually patients who've received a lot of these services, either through intensive sort of wraparound services and rehousing or who've had like engaged a lot with our Mercy Care Center. And what the patients and people consistently say when you ask them, they say, "Yeah, like my healthcare improved, "and yeah maybe I'm taking my meds." But the things that they consistently appreciate and if you ask them about the mechanism of what worked, they almost always actually cite like the connection of the person that they knew that got them through that was not just actually a connection to someone else. Like, part of it is like navigating the healthcare system. Yes, but part of it actually is just also that connection that really motivated them to get better and to adhere to their treatment plan and to do a lot of the work that it takes to get better as well. So, it really is I think such an important mechanism of reaching out to sort of these populations. And so I think, if it sort of flies under the radar 'cause we don't really have a great way to measure it and think about it in a lot of metrics that we collect. And so that's like the anthropologist side of me coming out, but I completely agree.

- And I think one of the things you just said there, sort of also is in sort of the beating hearts of all of us who do telehealth too of that, it's not just about the technology, right? It's about how we're using the technology, how it's implemented and it's that human touch too. And so, while we're rapidly trying to implement or to scale up, I think, it's usually a surprise to those stakeholders that have to be financing these and how much it actually the human, I can't think of the word right now other than cost, right? Like, the human labor involved in this, even if it's a slicker design on the telehealth or on the technology side, that is still such a key component to it all, so.

- Yeah, in anthropological terms, it would be called human infrastructure. So, just actually think about those social connections as important to kind of our societies as the highways we drive on or the trains we ride on depending on where you live, so.

- Well, I really appreciate the time. I wanna give people a little bit of breathing time, before their next meeting too, 'cause we usually run right up to the moment. So, but I really appreciate you coming Dr. Salhi, and always good to see you.

- [Bisan] Yeah.

- And to hear some updates to some of the work you've been doing, and hopefully this has been helpful. This is being recorded, so we will be able to have it for the rest of the, actually anybody is able to go onto it, I think, at least ACEP members or maybe even more broadly. But such an important topic, I think, when we're all sort of knee deep or higher waist deep or neck deep trying to work on these programs and innovate and to take that moment to really go back and say, "Are we exacerbating "or are we making assumptions for some of our users "and the people we're trying to help?" So, really appreciate the time and your expertise and your perspective, so.

- Thank you all. It was a pleasure.

- [Hayden] All right.

- [Participant] Thank you very much, excellent talk.

- [Bisan] Thank you.

- Yeah, have a great rest of the day and we'll see everybody next month.