COVID-19 and the Digital Health Policy Impact

COVID-19 has significantly shifted public policy worldwide and changes that we expected were years away have been implemented over the past eight months in response to the pandemic. Policymakers and communities need to remain diligent and flexible in responding to current needs and preparing for future policy changes due to COVID-19.

Although nations have diverse health policy environments and responses to COVID-19, one commonality is an expanded appreciation for and reliance on digital health.

Connected Health

In response to COVID-19, governments across the globe have rapidly placed health policies and additional flexibilities on connected health tools, such as telehealth and remote patient monitoring.

In the United States, federal and state governments put in place temporary health policy flexibilities for public and private payers to expand telehealth coverage and reimbursement. However, many of these flexibilities are scheduled to expire when the public health emergency declaration expires. At least a few states in the U.S. extended their policies to continue past the declared public health emergency. For example, Colorado permanently expanded telehealth flexibilities, including prohibiting insurers from requiring an initial in person appointment or imposing locations or additional licensing requirements as a condition for coverage.

A survey of U.S. specialists showed that almost 80% increased their use of telehealth tools due to COVID-19. In Medicare, pre-pandemic, approximately 13,000 fee-for-service (FFS) beneficiaries received care through telehealth in one week; by the end of April 2020, the use of telehealth increased by 130 times as almost 1.7 million FFS beneficiaries received such services in one week.

HIMSS conducted the Ehealth Trendbarometer: Telehealth Adoption in Europe, which included a quantitative survey and qualitative interviews of subject matter experts to understand the landscape and recent transformation of telehealth in Europe. The findings show that in Europe pre-COVID-19, a lot of the technical infrastructure was available for telehealth. However, usage of and support for telehealth varied. For example, in Denmark pre-pandemic, connected health was already a priority and was culturally accepted. In Spain, although telehealth was widespread, cultural attitudes stymied further progress. However, due to COVID-19 social distancing requirements and government support, connected health became a key priority across the board.

These major investments have expanded the evidence base that connected health increases access to care, reduces health disparities, increases patient engagement and, of course, is a key asset during public health crises. Therefore, HIMSS is advocating for continued access to connected health for all communities, particularly for at-risk and rural communities after the declared emergency expires. The U.S. Congress introduced The Protecting Access to Post-COVID-19 Telehealth Act of 2020 (H.R. 7663) to extend telehealth access to Medicare beneficiaries after the public health emergency declaration expires.

 

Interoperability in the Age of COVID-19

The impact of COVID-19 has exacerbated many deficiencies across healthcare systems, including how many organizations lack the ability to appropriately share information across the ecosystem. As COVID-19 has moved in waves across different parts of the world, the ability to share patient-level data has ascended to a critical component of any comprehensive response to the pandemic. Clinicians seeing COVID-19 cases need ready access to data to treat these patients and, from a broader, public health perspective, data needs to be available and accessible in order to track the locations of outbreaks and potential hot spots as they develop.

In the United States, Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services Office of the National Coordinator for Health IT have recently finalized health policy regulations that facilitate greater nationwide interoperability and provide patients with timely access to their health data to make informed healthcare decisions and better manage their care. Combined, these regulations place patients at the center of care delivery and empowers them with more control over their data so that they can be more informed decision-makers.

In addition, state and regional health information exchanges (HIEs) have produced significant value in data sharing and coordinating care as part of the response to COVID-19 and other public health crises. Integration and use of exchange services has the potential to improve care quality, make care more efficient, streamline administrative tasks and reduce costs in medical practices. However, each HIE has a different level of resources and infrastructure. When COVID-19 struck, some were prepared with existing resources, while others were ill equipped.

From an advocacy perspective, HIMSS has also been working diligently to prioritize necessary funding and technical assistance to implement modern health information and technology strategies and health policy that ensure timely interoperability and sharing of public health surveillance data. An important component is the work of HIMSS, along with several partner organizations, on the Data: Elemental to Health Campaign, a multi-year effort to modernize public health data systems, surveillance, and analytics at the Centers for Disease Control and Prevention (CDC) as well as state, local and tribal health departments.

The European Union (EU) is trying to address many of the same challenges in sharing COVID-19 related data in a coordinated and rapid way to develop treatments and vaccines. The EU-funded ELIXIR-CONVERGE Project is standardizing life science data and bringing it together from health systems across Europe to support more research. This data platform is one many efforts in the EU to help accelerate the collection and sharing of comprehensive data from different sources and allow researchers to upload, access and analyze COVID-19-related reference data and specialist datasets.

The digital health community is also incorporating broader privacy concerns into how it thinks about sharing data in the age of COVID-19. As Petra Wilson, European Program Director at the Personal Connected Health Alliance described, “We are working out how to strike a balance between what we need to do in the context of the management of a pandemic—which could mean rethinking an amount of privacy for the duration—and recognition by the individual of the value of sharing your data for that purpose, within your broader right to privacy.”

Overall, governments should look at taking several actions to support broader data sharing initiatives for COVID-19. Governments can capitalize on the increased levels of interoperability that has resulted from the COVID-19 pandemic, and highlight the benefits of comprehensive patient access, more extensive public health functions, and expanded research capabilities that it has brought to the entire community to address the virus. In the U.S., states are encouraged to deputize HIEs to collect coronavirus information from multi-sector health authorities and consider the role HIEs may play in enabling automatic submission of syndromic surveillance information to state health departments. Moreover, HIEs could be an important component in helping to collect COVID-19 test data from hospitals, public health labs, emergency medical services systems and community test sites (e.g. churches, drug stores, other retailers). Such a process could reduce the data reporting obligations of providers at the same time as providing them access to more data.

As we move to the next phase of the virus and focus on distributing COVID-19 vaccines, greater sharing of data becomes even more important as we determine the long-term effectiveness of any vaccine and track our progress in distributing it to all parts of the populace. Robust healthcare interoperability is a fundamental prerequisite to fully reopening societies across the globe and resuming normal everyday activities.

COVID-19-Related Privacy Concerns

The privacy and security of an individual’s health information are paramount considerations in addressing COVID-19. The public needs to trust that any data collection efforts used to combat the coronavirus are secure and will not be shared with outside entities that are not deemed appropriate by individuals. This objective is critically important as we discuss the next phase of interoperability and health policy, both within a HIPAA-regulated environment as well as outside the purview of HIPAA regulations.

A key aspect of HIPAA is the role of the patient as the primary authority in designating access to their data, and organizations should not be able to share an individual’s data for purposes other than treatment, payment, or healthcare operations without the expressed consent of that individual. However, much of the work occurring with third-party applications is happening outside of HIPAA and does not necessarily offer the same level of protections.

For example, the contact tracing apps that many states and localities are using to help mitigate the spread and exposure of COVID-19 sometime falls within the purview of HIPAA regulations but sometimes do not. The success of any digital contact tracing effort is contingent upon the public trusting that their personal information will be kept secure and will not be used for any nefarious purposes. The bedrock of a successful contact tracing program is a significant number of people having this sense of trust and volunteering their personal health and location information.

The University of Texas at Austin is using an app to help keep their community safe from the spread of COVID-19. As with much of the digital contact tracing happening across the globe, downloading the app is completely voluntary. In addition, no information will be shared with anyone outside The University of Texas at Austin.

However, recent survey data shows that only 29% of Americans surveyed said they would download and use the apps. More than 40% of respondents said that they did not trust any organization to keep their information safe, about 33% trusted large tech companies, and 14% said they would trust the government. According to the survey results, if data must be shared, people are most comfortable with this information going directly to hospitals.

In Switzerland, the government’s experience with its contact tracing app is comparable. A recent assessment from Swiss scientists and public health officials see app technology as an “effective complementary tool” to help respond to COVID-19. According to the Swiss report, approximately 20% of the population has downloaded that country’s contact tracing app and their research indicates that a significant number of users are actively interacting with the technology.

Overall, governments are encouraged to ensure that personal privacy protections are fully established in any COVID-19 response or health policy and that technology—particularly contact tracing app platforms—is leveraged when appropriate. The issue of trust in this technology as well as any broader COVID-19 privacy initiative is a critical one, and governments should implement steps to ensure that the public understands its options and that public awareness campaigns are put forward for when they need more detailed information.

Governments should not underestimate the importance of establishing trust and privacy in any program—the public health component of any nation’s COVID-19 response depends on it. In addition, the security of an individual’s information should be paramount. People need a sense of trust that their personal information will only be shared with entities that they explicitly designate, but also need to feel that this information will be held securely and not divulged to nefarious actors through cybersecurity breaches.

Social Determinants of Health and Equity

COVID-19 has not only illuminated existing health disparities; it has also exacerbated them. In the United States, COVID-19 disproportionately affects communities of color. In addition, despite the progress made in connected health, we are unable to eliminate health disparities without addressing the disparities in broadband access. In 2019, in the US, about 40% of rural communities did not have access to home broadband, compared with 25% in urban communities and 20% in suburban ones.

The pandemic directly and indirectly is exacerbating issues such as maternal mortality and morbidity and associated racial disparities. Pregnant women are not getting the prenatal care they need. The U.S. has the highest rates of maternal mortality among all western countries and the number of deaths is increasing. Low income, rural, Black and Native American women are the highest at-risk populations.

Digital health policies can support the push toward eliminating health disparities. Certain patient demographics and social determinants of health should be integrated into patient records in standardized ways, to identify trends, connect patients to social services, while at the same time, avoiding clinician burden and protecting patient privacy. Standardized data have the power to illuminate disparities and lead to interventions. In addition, broadband access disparities have further been illuminated through the shift to virtual care, work and education. Adequate broadband access needs an expansion in order to eliminate the digital divide that harms underserved communities.