Gregory Downing, DO, PharmD, PhD, is a healthcare innovation and public policy expert recently named to Cureatr's Strategic Advisory Board, which is providing expertise, insight, and guidance to the company's management. Dr. Downing is the founder of Innovation Horizons, a consulting practice with an emphasis on innovation and technology adaptation in healthcare. He was previously the founding executive director for innovation in the immediate office of the secretary at the U.S. Department of Health and Human Services (HHS). In this position, his primary responsibilities were focused on the promotion of innovation and entrepreneurship as valued attributes of workforce engagement across HHS. Prior to his arrival at HHS in 2006, Dr. Downing served at the National Institutes of Health since 1993 in research, policy, and program management roles.
Dr. Downing sat down with Cureatr to discuss trends and developments in areas including innovation, public policy, and medication management.
Q: What do you see as the biggest trends in healthcare innovation today? How can these innovations impact medication management?
Dr. Gregory Downing: The biggest trend in healthcare innovation remains the driving force for value. Everyone is trying to get greater efficiency and productivity out of the system. That doesn't mean people who are delivering ineffectively aren't trying to hang on, but they face steep competition from organizations adding ambulatory care, outpatient surgery, remote care, and other options to help reduce reliance on hospitals. Value-based cared in general is the biggest motivating factor for these institutions to pursue innovation.
There is also a lot of new options for care that we wouldn't have even imagined 10 years ago. This is largely attributable to technology and integrations concerning devices, therapeutics, and diagnostics. The strive for value and rapid advancements in science and technology are allowing interventions to occur in medical settings that would likely not have been deemed feasible even just a years ago.
Concerning the impact of these trends on medication management, there is becoming a greater recognition that people are taking a lot more medications. More specifically, patients with chronic diseases have a lot more to keep track of each day. There is increased awareness of and attention being applied to just how difficult it is for patients to manage their situation and that it's not much easier for providers to oversee and guide treatment selection, particularly when patients are seeing numerous doctors and specialist in their senior years.
The question now is: How do you integrate and avoid inefficient therapeutic management or adverse events? Both can be very costly, but the solutions, generally speaking, seem to be a combination of communication technology and solutions that deliver the ability to anticipate and ultimately prevent inefficient services or adverse events.
What's changing is the greater awareness of these issues. Most internists, family doctors, cardiologists, and other practitioners live in a reductionist world. They often don't have access to the bigger picture of a patient's situation. They can easily end up in a circumstance where they contribute to a complication without realizing it because they had no idea a patient was on different medications for other conditions.
The way these providers see the world now is what I like to call "binocular vision." The doctor you're seeing today is focused on that specific condition or circumstance that you seek help for. That's important, but the doctor also needs the ability to look more broadly and with some ease at what else is going on with you that might be contributing to the issues that are presenting today. This is especially important because the treatment the doctor prescribes for the patient can potentially increase the severity of another condition that the prescriber is unaware of.
Q: What has COVID-19 revealed about how our healthcare system uses data to improve population health?
GD: COVID-19 basically pressure tested a leaky system. The weak spots we knew or had insights about were exposed. That's everything from access to care, to information, to lab reporting systems, and the supply chain.
While most healthcare experts will admit that healthcare innovates at a glacial pace when compared to other industries, the pandemic really exposed that lack of modernization. I think the biggest gaping flaw on the information side is with public health reporting data. The causes for this are no great mystery. With the Health Information Technology for Economic and Clinical Health (HITECH) Act and American Recovery and Reinvestment Act of 2009, there was money allocated for improvements for state and local public health systems that never occurred.
It's been a chronic problem that the informatics around data on the public health side has been lacking. There is a lot of attributable accountability issues. Until there is a problem like COVID-19, most people aren't waking up in the morning thinking about the vulnerabilities of their state's public health reporting system to affect their health.
One silver lining of the health crisis, there has been significant mobilization and improvisation going on, with hospital systems working together to share information. Some of it has been at the medication level and being able to identify who has been tested, treated, and making more rapid diagnoses. Sharing information among health systems to be able to look at community spread has been important.
But it's also been a big challenge. Aside from the downfalls of diagnostic testing platforms, the information communication aspects of reporting on a local level to state and federal levels has been lagging. It's a reached a profile where even the average consumer is beginning to understand that there are some significant blind spots in our national public health system, largely in part due to ineffective data systems.
Q: What are the biggest challenges healthcare organizations must overcome if they want to successfully integrate innovative healthcare information technologies?
GD: A lot of it starts with money. When health systems used to build their own IT and operations, budgets were allocated to technology contracts. Now that world has evolved quickly over the last decade to include more network services. It's difficult, in many cases, for organizations to be able to perform strategic planning and build budget systems that accommodate the rapid need for things like artificial intelligence, distributed networks, and virtual care.
On the other hand, we've seen that those institutions which made investments in those and other areas have done quite well in maintaining their services and quality of their patient care via telehealth during the health crisis. That didn't happen overnight just because they signed a contract with telehealth vendors. Rather, these institutions had been integrating and developing the capabilities for people to work remotely and for patients to virtually engage with their providers and health information. It boils down to planning, resource management, and having a vision for how you see healthcare in the future.
A few years ago, the then chief executive officer of Mayo Clinic spoke about how, come 2025, the organization expected 50% of its patient encounters to occur via some form of remote health or telehealth. The people in the room gasped and then laughed because they thought this wasn't feasible. As we've seen over the last six months, telehealth has become one of the main ways people receive healthcare now. The prediction doesn't seem farfetched now.
Q: How do you anticipate public policy will affect telehealth?
GD: During this health crisis, we have seen a lot of relaxation of telehealth regulatory requirements and the de facto standards for what the Centers for Medicare & Medicaid Services will pay for. The general consensus is that while it might take congressional action to solidify these changes, the efficiencies, access to care, and patient satisfaction is so much better, at least right now. It's going to be difficult to try to roll anything back concerning telehealth because I think everyone essentially now recognizes and appreciates its value. I've spoken with lots of providers who switched to telehealth and find that their patients like it, with many not wanting to go back to in-person visits.
I don't think it's necessarily public policy that will be the main determinant of the future for telehealth. I think the provider and patient demand for wanting the improved access and ability to connect and get answers on the phone will drive the direction.
Q: What are some of the ways that you think we can improve medication management?
GD: Pharmacists have the potential to play a much greater role in both medication management, and care delivery in general. As we've seen in many states, pharmacists are taking on greater responsibilities concerning prescribing, providing immunizations, and performing limited health screenings, among other services. We need to start viewing and treating these professionals as vital to the medication management process.
In my view, something that needs to change is general medical education. That's not just education for providers, but also nurses and others involved in medication management. We must find ways to get them the tools to help better understand medication management. It's not practical for everyone to know everything about medications.
I was a pharmacist early in my career. Back then, the drug facts and comparisons book was maybe three inches thick. Now it's a foot thick. How do you manage all of that information? It's just not possible now since there's so much specialization in healthcare. The solution is likely a combination of tools, better education, and changing roles where pharmacists, pharmacy technicians, or specialists that don't have titles yet take on greater responsibility.
In the post-molecular genomics era, where diagnostics and disease definitions are being reformed on the basis of a test, clinicians struggle with what to do with that information and how to effectively use it. We need to redesign our processes so that the information is served in ways that the doctor doesn't need to spend so much time sorting through it to find what they are looking for. I think that will come. There are already tools that can help.
I also think we need to pay people on the basis of the information they provide and the complexities of care they are managing. An office visit for strep throat shouldn't be the same charge as dealing with a complex colon cancer diagnosis in which one is trying to determine a clinical trial or treatment regimen. Our reimbursement systems need to be adapted to compensate for the analytic work that is put into a particular patient's drug regimen.
Q: How do you view the role that Cureatr's technologies and services are playing in helping to improve healthcare delivery?
GD: At this point in time, the technologies and services are, unfortunately, still largely unrealized or unrecognized. The ability of Cureatr's technology and services to understand complicated circumstances is pretty novel and powerful. The need for what Cureatr provides is there, but there remains a gap between the need and recognition that there are solutions available that can make a patient encounter a much healthier and safer one. I believe that this is and will continue to close with time. The amount of literature surrounding the issues of suboptimal medication management have increased significantly, and as more awareness and understanding of the problem develops, so to will the awareness and understanding of solutions. We'll reach the stage where providers know that when there are changes in the clinical situation or new medications added to a patient's regimen, there are tools available that they can harness to help guide appropriate decisions. The leveraging of such solutions should eventually become part of routine visits.