Telehealth effectiveness and efficacy for indigenous peoples

Digital devices have changed the information landscape in many ways, be it through podcasts such as this, or accessing medical care. Today, any illness requiring professional medical help may be made easier to manage thanks to having a digital device nearby.

Professor Leonard Egede speaks with us again about how accessing care via Telehealth tools is another facet of his research on race, finance and inequality. Importantly, he sets out the lessons learnt over the pandemic of how simple, cheap telemedicine interventions can improve healthcare access for all.

Read his original research: http://dx.doi.org/10.21037/mhealth.2019.12.03 

Transcript

Will Mountford: Hello, I'm Will. Welcome to Researchpod. Listening to this podcast means that you have a digital device or access to a digital device, and this may make it easier for you to get medical help when you need it. As you'll hear shortly, any illness requiring professional medical help can be made easier to manage thanks to the existence of a digital device. In this episode, we are joined once more by Professor Leonard Egede, now at the University at Buffalo, to discuss how accessing care via telehealth tools fits together his other research on race and finance as drivers of inequality. Importantly, he sets out the lessons learnt over the pandemic of how simple, cheap telemedicine interventions can help with barriers due to distance and improve access to healthcare for every segment of the population. 

Will Mountford: Professor Egede, hello again 

Professor Leonard Egede: Oh, glad to be here. 

Will Mountford: For anyone who might not have heard our previous episodes, could you give us a quick rundown on who you are, where you are, what you do, and how that leads into our topic today about telehealth? 

Professor Leonard Egede: I'm a professor of medicine. I'm chief of the division of general internal Medicine and director for our center for Advancing Population Science at the Medical College of Wisconsin in the United States. I'm a physician scientist. Im a general internist by training, but I also have a training in health services research. My research over the past 24 years has really been focused on trying to address health inequalities across multiple domains and developing interventions to help address some of these issues. So, in the past episodes, we've talked about issues around health inequalities, structural racism, structural inequalities. We also talked about focus on evidence on how to use financial incentives to incentivize behavior change. And today we're going to be talking about the work we've done on telemedicine and how to use telemedicine to reach hard to reach populations. 

Will Mountford: Yes, I can only imagine what the last couple of years of pandemic and post pandemic, as much as we are post pandemic response in health has done for the face of telehealth. But to kind of draw those threads from the first two episodes along in terms of race and health and economic disparity, is being part of a disadvantaged group that might be reached by telehealth a different factor of those? Kind of a different face of it? Or are they three interlinked but distinct entities? 

Professor Leonard Egede: Yeah. So I think when you look at health inequalities, a key challenge for access to healthcare and we use the word access to evidence based treatment. So when you think about multiple aspects of care, if you live in an underserved environment, rural environment, where driving to a physician's office may be a problem, we're going to get clinical care is a problem, then access becomes a real barrier to care. And those who are disadvantaged are, ah, less likely to have the resources to make those long journeys throughout, ah, trips, being able to go to specialists when they actually need them. And so telemedicine can then become a bridge for those types of individuals because now you can actually get excellent care with the right specialists, with the right treatment option, just by having access to the Internet and being able to use virtual care as a way to do that. So I think on one hand, that's a huge advantage of telemedicine, is just being able to meet people where they are and get access to them where they need to be. Now, the disadvantage of telehealth is that again, depending on the environment, bandwidth could be an issue. And so for some populations who are the same individuals who will be hard to reach, if you live in a rural area, you may not have the right bandwidth for telehealth, but by and large, telehealth becomes a breach for a lot of individuals and can actually help address some of the challenges we see in providing care to multiple diverse populations. 

Will Mountford: Now, use the phase there of hard to reach, which brings in elements of the geographic disparity of being hard to get to. But then also that reach is an active effort and to compile some of the lessons from the pandemic, of trying to reach out to people when we couldn't see them in person, when we couldn't be in the same room. What kind of broad stroke lessons have we learned about doing active outreach in healthcare that you think have been key and will be key to framing the rest of our conversation? 

Professor Leonard Egede: For many of us who were in the space of telehealth for very many years, I think the pandemic essentially accelerated the use of telehealth because of the need. There were so many laws in place that made it difficult, difficult to cross state lines, to get care across different barriers. And when the pandemic hit, there was actually a necessity to actually break down some of those barriers. And so several laws were actually passed or exceptions were made that allowed people to actually provide care across state lines, to actually provide care virtually and get reimbursed effectively for virtual care. So while the pandemic was a disaster, it was actually almost a blessing in disguise for advancing the use of telehealth technologies. And so several bills and modifications were passed to allow billing for virtual only care. The ability to actually 

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Professor Leonard Egede: provide us to actually practice across state lines, providing care across different modalities, and being able to build them as equivalent to in person care. So those things really helped during the pandemic to help make access to care available to all. 

Will Mountford: Mhm. The pandemic came not just with the immediate health concern of the Covid-19 virus, but also the mental health crises that came with lockdown, that came with stress and exhaustion. 

So to start bringing some of the elements of your recent publications, there was a 2015 paper that I know focused on veterans, especially looking after their mental health. What does telehealth do for kind of the non physical elements, shall we say? 

Professor Leonard Egede: Yes. So one of the big challenges with the pandemic, and then pretty much it's really social isolation, and some of that is a mental health depression that comes around. So this study where we're going to discuss right now was actually a study that got funded in 2006 by the Veterans Health Administration. At that time, the question was, can you provide telepsychiatry? Can you actually provide depression treatment via telehealth modalities? And the prevailing thought at that time was that, you know, it was not safe. Patients would not accept it. It may actually trigger reactions. And if people got sick, what's going to happen to them when they're at home, they're not in the clinic. And at the same time, the VA was inundated with the need for veterans who were returning, who had a lot of mental health needs. And so the question was, what could we do? So we put this idea together with some of my colleagues, and the question was, let's test this idea. We believe that we can actually deliver effective mental health care via telemedicine and that it will not be different from face to face. So we actually set this study together, what we call a non inferiority study, to compare if you actually provided depression treatment via telemedicine versus in person, would it be equivalent in terms of. Or would it be non inferior is what we use in that study. We took veterans who were about 58 years and older who met criteria for depression, and we randomized them to in person treatment versus telemedicine delivered. And just to give you some perspective, at the time this was going on, there was only one vendor for the kind of tele video technology we actually had. And so it was a sole vendor that was actually available to us and those devices cost about dollars at that time. So here we were. So between April of 2007 and July of 2011, we screened about 780 individuals and we randomized about 200 and 4120 to telemedicine and 121 to same room m. And the idea was to actually provide eight sessions of behavioral activation, which is a treatment for depression through both modalities, and then follow the individuals and look at twelve months, what happened to their depression care. So we're looking at both their clinical outcomes. We looked at depression scores, we looked at their anxiety scores, but we also looked at things like quality of life. And then we had assess engagement, how likely were they to stay in treatment? And we also looked at safety. Were they safety concerns? And at the end of the study, what we actually found was that telemedicine was non inferior to in person, and so that people could actually get the same results from eight sessions of behavioral activation treatment. We got the same results telling medicine as it was face to face. So the idea here was that this telemedicine modality was non inferior to face to face. And this actually shifted the thinking about how to provide mental health care to veterans. So when we did that study and um, we published, the results was published in Lancet, they got a lot of press and we then began to ask a question. We actually look at safety. And uh, we realized there were no differences in terms of complications, suicide rates, safety issues, calls to emergency service. And what we actually found out was we became very evident was, when you're doing this, bye telemedicine, you actually saw the patient, and if anything happened, you could call ems to their house as opposed to when they left clinic. And now they leave clinic, you don't know how far before they get home. So there was actually some advantages. Then after we've published this, it turns out that Department of Defense was doing some work. They're trying to figure out what to do with active military because it's very expensive to train soldiers. So when they are deployed, the question was, if someone had a mental health concern, what do you do? Typically in the past they actually ship them back home from theatre. DoD was interested when our results came out, when he saw there was no difference, they actually asked us to help consult for them, to see how to tailor and modify and be able to provide telemedicine for active duty soldiers so that you could actually treat them in theater. So our team actually helped consult with them and they actually ran a trial that demonstrated that you could actually do treatment for active duty and without risk. So again, this was in an era when we were very much behind in terms of what we needed to do. We published this paper and then our team did another study. We actually wanted to test this for PTSD. So now we've done it for depression. We actually did another paper. We actually looked at non inferiority for PTSD and we found similar results. Another member of our group actually looked at military sexual trauma 

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Professor Leonard Egede: and ah, using telemedicine, and similar results. So again, what we actually demonstrated over the course of those series of studies was that telemedicine for mental health was just as equivalent as ah, face to face. And this was a huge shift in the field at that time. We also then looked at cost effectiveness. The big question was always, in addition to the treatment, what is the cost of doing this? And in our cost effectiveness analysis. So we had two groups, those who were in person, and we looked at their cost pre treatment and post treatment, and their cost was higher, about $3,000 higher pre and post, whereas for those who are telemedicine, the difference in cost was about $900 pre and post. So it was essentially cheaper. The cost was actually less for those who got telemedicine vessels, those who actually got in person. So again, this demonstrated that telemedicine is not only effective clinical outcomes, but it's also cost effective in terms of cost of delivery. 

Will Mountford: Is that including the thousand pounds per device, if that was still the current cost for that, because, I mean, if I think about telehealth now, I just imagine the phone in my hand. 

Professor Leonard Egede: Yes. So what changed after that study was funded? Because, you know, at that time, again, this was an issue of the era, technology. As technology scales, cost comes down. By the time we were testing future studies, a couple of other studies we had moved from, we started using iPads. So instead of giving them a clunky device, we actually gave them iPads. And at that time, our next study, we actually started using computers. We actually gave them computers that were small and portable. And it cost us about half the price the device. And then we finally got to a point where giving Samsung tablets, and we're paying about $300 per tablet, and then we got to a point where we actually using cameras, they actually could attach to their computer, we actually give them the cameras. And now we are cutting the cost down to about maybe $50 per person. And now most people have a phone and we actually do a lot of these things on the phone. And now you actually just use video apps and it's so much more cost effective. So I think over the years it was cost effective at the time. We're doing this with devices about a pop now. You can imagine how much we can scale now with more cost effective options for technology. 

Will Mountford: And this is all weighed against, you mentioned the cost of bringing people back, especially with the veterans from active deployment to do the same room test. And then how does that compare to the cost of no care if there was, you know, a control group of did not receive care in terms of the cost effectiveness for any mental health support to this telehealth support. I mean, if can you put a dollar value to something like that? 

Professor Leonard Egede: I don't have access to that data because I wasn't part of the follow up studies. But you can imagine if you had someone who was active duty, you had to ship them back to in state. So that's a well trained soldier now that has to be sent back. But in addition to that, the cost of bringing them back, the cost of having to replace them in theater, I mean, those costs are huge. I mean, you can imagine what that cost. But I think the more important thing is that it actually allowed the individual to remain with their team. Being able to stay with your team and getting care it made it a lot more manageable as opposed to the stigma of having to leave. And everybody knew you were sent back home because you had mental health issues. So I think it has really allowed us to be more effective in multiple scenarios, whether it's at home, whether it's in theater, whether it's in educational settings, it just becomes really a lot of options. 

Will Mountford: I suppose there's been any follow up. I mean, if we think about a paper from maybe five, six years ago now to see what the long term cost effectiveness, if you think about quality adjusted life years or five year survival, to compare it to some of the medical reports that I've covered, to see 2023, 2024 pandemic may be a confounding factor here, but what that long term survival is like. 

Professor Leonard Egede: So we had talked about because we know we could have actually followed up some of these veterans long term. But again like you said, the pandemic came around and pandemic changed. So all your data, in terms of cost, in terms of effectiveness, is pretty much no longer there at that time. In this same analysis, we actually look at individuals who had diabetes. Mhm. And it turns out that those who got telemedicine actually had better outcomes for their diabetes. So they had depression and they had diabetes, and we actually just took a subset and we said, okay, let's look at whether this telemedicine for depression had a bleed over into chronic disease. And we actually published a couple of papers that actually showed that there was benefit in that group that got telemedicine. I was just being more engaged with the provider being able to actually get. So it actually galvanized them to get better. So I think there are lots of benefits and we haven't done any more follow up studies now to track some of these individuals, but I know there are several groups that have actually done it and the cost effectiveness has persisted over time. 

Will Mountford: Mhm. Well, to kind of widen the scope before we narrow it again, we've talked about the initial papers, we've talked about the veterans follow up to look at kind of the global view 2020 onwards. And then from there we can start to hone in on the structural barriers to indigenous well being, those hard to reach groups that you've mentioned. 

There was the global application paper in 2020 that was looking at kind of the holistic review. Can you talk me through some of the scope of that review in terms of what went into it, what the background was? 

Professor Leonard Egede: Yeah, so this is a paper that we put together, our team was after we did some of this telehealth work, and I also do some work globally with indigenous populations around the world. And so one of the questions we're asking ourselves was, how well can you use telemedicine for indigenous populations? And what do we know for both physical and mental health? And so we actually did what's called a scoping review. And in that scoping review, we took data we actually looked at literature around, and we're asking ourselves what's actually out there? We actually identified all papers that were published in the English language, that had age greater than 18 adults, was focused on indigenous people, and used any technology based intervention, and they had to have at least one of the following mental health conditions, either depression, PTSD or suicide. And then for physical conditions, we looked at things like mortality, blood pressure, a one c, cholesterol, quality of life and outcomes. We identified about almost 3000 articles. And then when we finally scaled down, we actually included six really good papers that covered the scope of what we're looking for. And we found far fewer papers than we expected because there's been very little that's been done in indigenous people. This was in 2020. So obviously, fast forward now to 2024. There may be more studies, but what we actually realized was that a lot of the studies were conducted in the United States. One was conducted in Canada, and two were conducted in New Zealand. There was nothing from sub saharan Africa, there was nothing from Asia, nothing from the rest of the world. So again, this tells you very clearly that there are gaps in terms of use of telehealth, and these are the populations who really need access to care. So that raised the question, what do we actually need to do to actually improve care for some of these indigenous populations? 

Will Mountford: Well, that leads into what the structural barrier for an indigenous community might look like in terms of comparing Australia to Canada. Is there a unifying aspect between those two? I mean, those are opposite sides of the world. How much unifying can there be? 

Professor Leonard Egede: I think context matters, and so for most implementation type work, you always have to pay attention to the context. So Australia has actually done a really good job at creating hubs for telehealth. And so they've actually had been more connected maybe because of their geographic divide, they've actually made very intentional strategies to create and use telehealth effectively. So Australia is actually unique in that regard. Canada has some very much like America in terms of the options, but they have a large indigenous population, the areas where there's very little being done in other countries. If you remove Australia, Canada and New Zealand, and you start looking at Africa, you start looking at other continents, very little has been done. So we have done a lot of work. My team, we've done a lot of work in Panama, in Central America, amongst an indigenous group called Ikuna Indians. And so I've been working with that community now for maybe almost 1015 years. This is a community that has about 350 islands. They are off the mainland of Panama, and you have to take a prop plane to get from those islands to the main part of Panama. It takes about an hour to an hour and a half for flight, and those flights are expensive. Most of the indigenous people actually use their boats. They take boat rides. It takes about 6 hours by boat to get out, so you can imagine. And then the way the healthcare system is structured in that environment is that the government has satellite locations where you actually have clinics and they have hubs of specialty care, maybe about three of them. And so when people are sick, getting care for simple, I mean, we've had cases where people had dermatological conditions, skin cancer, that someone just looking at them would have made a diagnosis. But the cost of getting to mainland was so much that many of them will wait five years, ten years to actually get care. So this is an example, and this is just one indigenous community that we've actually worked in, you can imagine all over the world, other indigenous communities where transportation is an issue, where cost of getting around is an issue, and the ability to use technology to provide care, and how much of a difference that will make in terms of health of indigenous populations. 

Coming back to our earlier discussion about some of the structural inequalities, you start seeing that many of the hard to reach populations, marginalized populations, are at multiple disadvantages. They have financial disadvantages, they have geographic disadvantages, they have transportation barriers, and they also have access to healthcare barriers. And so we believe that technology may be one of the strategies to actually bridge some of those gaps in healthcare. So, for example, 

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cell phone penetration now in most countries, doesn't matter where it is, is probably in the 90% range. And many of those are, ah, smartphones that actually have the ability to do audio and video. And so now we actually have the ability to even in remote communities where they have cell towers. So now you can actually provide care in a very meaningful way. So rather than waiting for finding ways to get people to healthcare, maybe we need to start thinking about how do we get healthcare to them, using innovative technology, using strategies that will make it a lot easier for people to actually get services. I mean, there are already studies that are being done right now using things like WhatsApp to provide education. And so most communities are connected by WhatsApp. You can send video chat, you can do audio chat. So how do you leverage naturally what people already are using, rather than creating new technology, new devices, using what people use routinely, and embedding that into healthcare, and making that part of what that relationship is. So we are very interested in trying to identify how can we make telehealth more mainstream, and how do we move healthcare from systems and hospitals and clinics to communities where people actually live, where those who are really sick needed care? And I think that is a phase that really needs to become more and more of our conversation if we really want to address structural inequalities in health. 

Will Mountford: And health outcomes as broader hurdles to the implementation of telehealth. There's going to be some issues along the way in terms of development and deployment. I've heard separately in conversations with doctor Diane Wepper from Charles Darwin University in Australia, that in her work with remote and indigenous communities, she has faced the problem of cell towers being deactivated. That, you know, if they're trying to text people, but those masts are being turned off for the 2g or 3g signal to make row for uh, 4g. That means that the WhatsApp would work, but the people who don't have the smart devices can't use that and they can't reach them with the text device anymore. Do you see that there is a problem, or a potential problem in terms of pace of telehealth initiative developed alongside the pace of getting the required technology to those communities? 

Professor Leonard Egede: This is going to require a very strategic investment. If we truly believe that healthcare is important and that these populations need access to healthcare, then there needs to be strategic investments by uh, private government partnerships. And so many of these cell towers, they need to be installed, some of them need to be managed, repaired. And I think that investment, it can be used for multiple purposes. It creates access to connectedness for these communities, it can be used for financial transactions, it can be used for communication, but it can also be used for healthcare. So I think that's where government comes in to actually invest in those types of infrastructure across communities. And then once that infrastructure is there, then healthcare can then layer all the different resources and technologies available to them, provide care in a more meaningful and effective way. 

Will Mountford: And then another potential barrier would be that, well, it frankly sounds hard getting to reach those communities, to build that initial rapport, to get that foot in the door so you don't just kind of blast right in, put a cell phone in the middle of the jungle and say, I'll call you in two weeks. There's a lot of groundwork that needs to be done. Is there the professional appetite for taking on that challenge? 

Professor Leonard Egede: There is a whole movement now towards using what we call community at workers. Mhm. As a community, workers are individuals who tend to be from that environment. Some of them could be lay individuals who have some training, others could be semi trained. And I think as we move towards this idea of providing care for how to reach populations, we really need to embrace the use of community health workers. And so you can imagine some of the challenges we're facing. If you actually had someone in the community who lives in the community, knows the community very, very well, and then becomes the connector between the communities and health systems, that creates opportunity and leverages. So now you're creating employment for that individual. They are well known, they are respected in the community, and it gives you access and the ability to leverage that technology in a very meaningful way. I think there are barriers, but there are strategies out there now to address some of these barriers, especially if the will is there and there's willingness to invest in developing some of this infrastructure. 

Will Mountford: With the willingness to invest, is that going to happen? Many economically favourable nations are turning inwards. I know the UK has pulled a lot of its foreign aid. I know that there are external pressures on budgets in the US in terms of what aid is being spent. Where do you see this as being something that the powers that be will find that they can afford for non residential citizens. 

Professor Leonard Egede: It has to go both ways. One is that we are one universe, as you start thinking about is we're global and uh, we travel now people are moving from countries to countries. And so it's actually in the best interest. We saw that with the pandemic. It's actually in the best interest 

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Professor Leonard Egede: for the developed world to actually invest in the developing world. But there's also the importance of accountability for the developing world. I mean, I think you just can't give aid without it people being held accountable for what the age is being used for. And I think one of the big concerns people have is the corruption that is actually tied to how these funds are being used. So I think it's going to require the developed world to actually remain focused on trying to achieve laudable goals of providing healthcare for all, but then also the developing world to actually be held accountable for how to use the funds. And because it doesn't make sense if resources are being spent and the resources are being siphoned into people's private pocket, I mean, I think it's just not right. So I think it's a balancing act of providing the resources and holding governments and leaders accountable for the use of those resources so that their populations can be served. And then the other thing they say is that communities also need to be activated. They need to be able to understand what is being sent in, what resources are there, and then being able to hold their governments accountable for how those resources are actually being used. 

Will Mountford: Especially when you think about holding the government to account, bringing back the elements of your work in finance, in racial disparities, that uh, this is, as you say, all part of one story and one universe. 

Professor Leonard Egede: Exactly. A lot of the work we do now is really this idea of social medical integration, that people live in communities, health is the ideal state and sickness is just one aspect of what people actually deal with. And so we can't actually begin to focus on when people are sick. We need to think about holistic approach to healthcare. How do we keep people healthy? How do we create a safe environment for them? How do we create jobs? How do we empower people to actually take better care of their health? These are, ah, the strategies that will allow us to create a healthier community and allow people to be more empowered to actually take responsibility for their own health. So I think as a society, we need to move away from just this medical model where it's about when you're sick, you come to the hospital, when you start thinking about health as being holistic, and it encompasses all aspects of your social environment, and that medical and social need to be integrated and made part of what we actually invest and spend resources on. 

Will Mountford: To re raise the question, I've said at the end of the last couple of episodes, what does this research mean for practitioners in the field, for policy makers who should be hearing this episode, and what can they do with the information that they might have learned today? 

Professor Leonard Egede: I usually like to think about this in three core groups. So you have the clinical, the clinicians, people actually see patients. And I think clinicians need to recognize that disease is a function of both the environment and the individual. And so we need to start looking at life from what we call the socioecological model that says that individuals are nested within environments, and environments are nested within communities, and how does the interplay and what that does. And so that when people are making recommendations, they actually pay attention to where people live, the environment that they in, and the resources that are available to them. And the factors, adverse factors, may actually affect health. And that will actually allow clinicians to be more empathetic, allow them to be more balanced in their perspective, and give them insight into what is needed to provide optimal care for patients. And then you think about the research. We always need more research, but we need what we call now implementation science, which is research on how do we take what we know works. We've shown now that telemedicine works. How do we get that telemedicine into the hands of people who really need it? And so we need to think about studies that look at context, that look at environmental drivers, that look at policy drivers, and be able to integrate that. How do we work with governments? How do we work with health systems to actually roll out programs that are likely to work? And that's where research is needed, and where we need more research in terms of delivering evidence based treatments to the right people. And the third is policy. And that policy piece, one, we need to actually make data more digestible for policy makers. People, you know, they need to be able to understand. You drill down so many of us now, m start, we start thinking about writing policy briefs. So rather than, you know, you write a paper like this, you know, 5000 word paper, and very few people are going to read it. How do you digest that into a brief that the average legislator can actually read and actually make sense of it? But then also how do we begin to get, make compelling messages so where we can actually put things in the hands of advocates who can then say, using this information, they can actually now go in and lobby and actually get laws passed, actually favorable, and they address this issue. And then the last piece in terms of policy is, you know, I think you mentioned this earlier, we are becoming more and more polarized, and this is not an american issue. It's happening in the UK, it's happening in Canada, it's happening all over the world. And we're getting to this point where we're actually losing sight of our humanity and the common factors that hold us together, that we're all human, we have the same interest. We want to live a safe, enjoyable life. And the more we polarize, whether it's conservative versus liberal, we lose sight of the unifying factor that we're all human and we all want the same things in general. And so I think the more we are able to get people to move away from extremes and really come to the middle, most people actually 

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Professor Leonard Egede: live in the middle, and where do we actually get people to actually function? What are the best options for people who are in the middle? I think that is going to really go a long way in changing and helping us get to that future state. 

Will Mountford: Well, I can't think of any better way to wrap things up than that. Thank you so much for your time again today, today. 

Professor Leonard Egede: Thank you. Really appreciate being able to have this conversation.