Technology Innovations for Older Adults: The Unexpected Consequences of the Pandemic

Technology Innovations for Older Adults: The Unexpected Consequences of the Pandemic

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We're happy you could join us today, we will  be hosting David Lindeman. And if you do have   questions for David and his guest presenter Dr.  Courtney Lyles as they go through their talk,   please put those questions in the chat, and we  will field those a little later in the hour.  

So today, the talk is entitled "Technology  Innovation for Older Adults and the Unexpected   Consequences of the Pandemic". David Lindeman,  PhD is the director of Citris Health. Lindeman   has worked in the fields of healthcare  and long-term care for nearly 40 years.   His current focus is working  with researchers, entrepreneurs,   and investors on the incubation, startup,  evaluation, and scaling of technology-enabled   healthcare solution, including initiatives that  address critical health challenges through mobile   and cloud sensors, Telehealth, robotics,  assistive technologies, and data analytics.   Last year, he was appointed by the governor  to the California Commission on Aging. As a   colleague and a friend to OLLI, David is also  the co-convener with myself and Professor George   Brooks on the Aging Research and Technology  summit, which is now scheduled for Fall   2022. Thank you all for joining us,  and please, here is David Lindeman. Thank you very much, Susan, for that very kind  introduction. And again, welcome. Good morning  

to everyone who's listening today. And a special  thank you to Osher, in terms of OLLI's program   here at Berkeley, which is so outstanding in terms  of bringing you information. I'm delighted to be   here as part of that today, and to share with  you some of our lessons that we have seen through   the last year and a half, and even more  importantly, what it means for us going forward.   I'm delighted to be joined by our great colleague  Courtney Lyles, who I will introduce shortly, who   is both an adjunct faculty member here at Berkeley  and at UCSF, a faculty member who has been doing   outstanding innovative work in this space as  well. So today, we'd like to take you through   a few different items to share with you  this background. And as Susan suggested,  

we'll also be looking forward to a dialogue  in the exchange with you at the end, through   questions that you may have in the chat. So,  the agenda for today will be, first I will lead   off and share with you some of the observations  we've had of what has occurred during Covid-19,   and both the opportunities and challenges  that we've seen from a technology perspective   in this area. We'll then turn to a key area that  both Courtney and I are passionate about, which   is Telehealth. And looking at some of the models  and programs that we are both engaged in here,   and have Courtney give you some of the updates in  that area, followed by my presenting some of the   Telehealth projects that we've been engaged in at  Citris here at UC Berkeley. And following that,   Susan has asked for a few points to be shared  with you, as she has said about some of the major   issues that are going on here in California.  And I will mention our master plan on aging,   and some of the other new technology and  policy developments we see in that area.  

So without further ado, I'd like to start taking  us through. Again, Susan provided background,   I'd just like to confirm for you that I am  responsible for a number of programs, but   my passion is around gerontology and looking at  projects that can help all of us as older adults   move in this area. And we do that through Citris,  and our Citris Technology and Aging program. And   Courtney, again, not only adjunct professor and an  innovator at the School of Public Health here at   Berkeley, but working out of the departments  of medicine, epidemiology, and biostatistics   at the Zuckerberg San Francisco General Hospital,  has been an innovator in this space and has used   data and innovative technology solutions to reach  all different types of populations. We just came   from a wonderful meeting yesterday of looking at  collaboration and how we work across disciplines,   how we bring different expertise to this area.  And as you'll see today, how we are going to   have some wonderful opportunities moving forward  in the future. One quick point for those of you   are not familiar with Citris. Citris and the  Banatao Institute, which actually stands for  

the Center for Information Technology Research  in the Interests of Society. We are actually   a 20-year old organization that brings  together not only multiple disciplines,   but multiple campuses. We're responsible from  our Berkeley home, bringing in individuals   and faculty and researchers and students from  UC Davis, UC Merced, and UC Santa Cruz. And   our goal is to take technology, particularly  information technology is the focus of Citris,   and making sure that it can help as a channel,  as a conduit to helping all areas of society.   While I run the health program, we have programs  that are now looking at climate and resiliency,   robotics that benefit people, individual  ways that technology can help our workforce,   even into issues on how do we engage more people  in this space, particularly women into technology.   And how, ultimately, do we even impact policies?  So, I'd like to now move into some of the issues   around what we have learned and seen over  the last 18 months. But in that context,  

I will share that we work on a whole range of  new technology solutions, and some very basic   technology solutions that really do help not only  older adults, but all elements of our population.   Not just individuals, but families. The workforce,  particularly the healthcare workforce, in this   space. And how we can better use technology  to improve not only our health, but our  

well-being. So, what happened during Covid-19?  Well, working with a number of colleagues,   we have a great deal of anecdotal information  of what did happen and what didn't happen   during Covid. And what's intriguing is that  these five areas - smart buildings/smart homes,   the use of Telehealth, changing how we get  information through wearables, even virtual   reality and robotics - all of a sudden started  coming into their own. And behind it all,   the use of data. I have the term "artificial  intelligence" or machine learning there,   but it's really machine intelligence, and how we  use information from these different devices. So,  

why did this occur in this regard? Well, I think  everybody listening today knows the obvious. We   went into lockdowns, we had issues related  to how could we communicate with each other,   we had isolation, we had to come up with new  ways to not only have individuals reach others,   but how we help ourselves. So, one of the  interesting things that our colleagues,   particularly at several of the larger  technology companies, noted that the   idea of a smart home with everything connected  came into its own. This has been starting with   everything from smart security cameras and  being able to monitor things within a home,   but this has really expanded remarkably over  this last year and a half. And again, the idea   of how these different types of technologies can  be connected, and support people where they are.   Another area that was significant in terms of  its change was the idea of wearables. The fact  

that Fitbit was picked up by Apple, and the  fact that we have these different types of   devices now that collect information  and can share it remotely,   became ever more important. Not only for us as  individuals, but particularly in healthcare,   getting information to individuals who need it,  whether it's a family member or provider. We saw   tremendous growth in this type of use across all  elements of society, but particularly for those of   us who are older. What was intriguing, though, is  that we also saw the true advent of different, new   technologies that we had not seen before really  catching on fully. And virtual reality or VR,  

or even augmented reality, AR, have become into  their own, not just for being able to communicate   or entertainment, but literally for its devices  to help in issues such as pain management. There   are several new VR devices that when used with  individuals, have already been proven to reduce   pain by 25%. So, we saw a great deal of change  in that area. But surprisingly to some of us,   we even saw the issue around robotics - and when  we talk about robotics, we're speaking about not   only Robbie the Robot or something tangible that  will move in a space - but also the use of data   that drives different devices of this sort. So we  did see these different mechanisms that started   coming into their own, particularly in buildings,  whether it be assisted living or other residential   settings where people had to stay separate. And  we saw a number of companies move forward with   movable devices that you see on the screen, that  could actually carry material for individuals   and deliver them. We've seen it in hospitals,  we've seen it in hotels growing, but now we're   beginning to actually see the ability of  this, of robots, to be very more practical.  

Another example is a company that came out of our  programs here at Berkeley called "Safely You". I   think a number of you are familiar with it, but  "Safely You" is now one of the gold standards   in falls prevention. And the program, that  was started and founded by George Netscher,   really did an amazing job of using cameras  with artificial intelligence data backend,   that could monitor individuals and ensure privacy  and security, but get information about a fall,   but even more importantly, prevention of falls, to  the proper people, so that we could make sure that   people would be safer. Wonderfully, this program  has had tremendous success, and has actually   been accepted now as one of the primary gold  standards in assisted living here in California,   supported by the Department of Social Services  because it results in not only fewer falls, but   fewer visits to an emergency room. And to show how  far it's gone, it is now actually being covered by   insurance companies. So, we're very excited about  these types of issues. And again, I consider this   a part of robotics, but also data science, as  things that we have seen really coming through   to help people, particularly because we had to  do with the deal with isolation, remote areas,   and connecting people during this challenging  last 18 months. I'd like to now turn into the  

fifth area, that I think is really exciting and  we're seeing huge changes, and that's Telehealth.   And to do so, I'd like to turn the program over  to Courtney, who will share some background   on Telehealth and how her programs have been  really been game changers here in California,   and beyond. So, I'll stop sharing my  screen, and let's turn it over to Courtney. Wonderful. Thank you so much, David,  and thank you all for having me.   I'm gonna talk a little bit about Telehealth  today, but I'm gonna come at it from a lens   on equity. And so, I would love to talk about  sort the ability to implement something like   Telehealth at scale, and then the ability  to ensure that it's working for everybody.   So, the way in which I've thought about the last  year and a half, or a little longer than a year   and a half given Covid, is that it's really been  a moment of progress and opportunity, and I think   that's what David really just highlighted really  well, and also some gaps and challenges specific   to digital and digital modalities in the time of  Covid. I think there's a lot of things happening  

across multi-levels that brings us to where we're  at today. Um, we've seen high interest among all   sorts of patients and community members in using  their their digital tools and wearables, trackers,   like we just went over. And we have community  organizations that have been doing community work,   and have been able to mobilize for Covid in  ways that are frankly, truly heroic and amazing.   The same at the healthcare delivery system  level, who've really restructured and tried   out Telehealth in a completely different way than  they were trying it out prior to the pandemic.   And then we have industry coming to the table  with resources, and in a policy environment,   we're actually trying to build infrastructure  for everybody to have access to digital tools.   But on the flip side, I think there's a  lot of other things that are coming into   into view during this past year and a half  that I think we really need to pay attention   to if we really want to have an equitable  rollout of Telehealth and other digital   strategies moving forward. And that has to  do with everything from individual level  

motivations and trust, to structural  disinvestment in our communities,   thinking about healthcare system variation,  about how they were able to implement Telehealth   and what Telehealth looked for them on the  ground, the industry really thinking about   health equity and the equitable rollout of  their products, and all the way through,   better policy mandates to improve the strides  that we've been making over the past year.   So this is sort of, in a snapshot, I would say  we're really out of crux. And now is the moment,   I would say, to take what we've learned with  Telehealth and to move forward into the future.   At the patient level, I just thought I would show  a little bit of data about where we're at. So,   this is pre-Covid data on Telehealth from a  national accelerator called Rock Health, which   was one of the few groups doing sort of national  surveys of different digital technologies. And   this was 2017 data, but I think it's really  interesting to think about in the pandemic   world, because you can see here that they had  an overall national survey sample who was using   telemedicine around 2017, and then they did  oversampling of four groups that are shown   across the columns at the top. So, chronically  ill seniors, a group that they call vulnerable  

individuals - so, people who are Medicaid health  insurance or are low-income - the worried well,   which was sort of more activated young people  who were looking for trackers and wearables,   and then just an overall aging adult population.  And you can see, specific to telemedicine,   some pretty wide variation in who had access  to telemedicine prior to the pandemic,   with some of these groups having really low uptake  in use. Those patterns are really similar for some   other things on this graph, like wearables. But  I wanted to also just call your attention to  

the fourth row there, about searching for online  health information, and really make the case that,   yes, there's variation of what we were doing with  Telehealth pre-pandemic, but actually everybody   is interested in using tools and online tools  to improve their health. And so, we're in this   situation, in this pandemic situation, where  we've launched an entire new modality of care,   and we have high interest in people trying  out things, but actually probably differential   ability and differential structures in place  to allow everybody to use it in the same way. So, when I think specifically about things  like Telehealth, I think about all of the   three things that I'm guessing this group has  thought a lot about before. It is actually a  

multi-level scenario to allow all patients to  access Telehealth. We actually have to have the   right devices and the right data, which is  actually not universal across our country,   and then we need the skills to be able to use  the types of technologies that we're offering.   And all three of these came into play  during the pandemic, especially at   the safety net healthcare delivery system where  I'm based at San Francisco General Hospital. And I wanted to underscore this point that the  skills piece of this is. We know nationally,   for example, how many people own smartphones  and how many people are online - and I think   the pandemic's shone a light on actually a  significant group and a significant group   of older adults who actually are not online  and not able to access technology - but the   skills piece is something that there's less  data available at a national level. And so,  

this is just data from San Francisco about  sort of who's online, and both who reports   basic digital literacy skills in being able to  use their technology in a way, like searching   for websites and those types of tasks. And  you can see here, there are some subgroups   even within a tech-connected city like San  Francisco, who actually have some pretty big gaps.   And so, this is the group that I think,  when we think about Telehealth rollout,   where a majority might be able to use it, but  there's actually a pretty sizable proportion   of people who need additional systems and  supports to be able to use what we're offering. And then I wanted to set the stage about the  clinical side, right. I'm based in a healthcare   delivery system, like I just mentioned, I'm  a health services researcher, but I've been   based in primary care in a healthcare system.  And there's actually a lot that's gone on,   on the other side of how we've offered Telehealth  to patients over the pandemic. I would argue,  

actually, that clinicians and systems face the  same kinds of barriers to offering Telehealth   at scale that patients do. And while many, many  systems like UCSF Health and others, who had   some Telehealth happening before the pandemic,  were able to largely scale up their practice,   places like where I work at San Francisco General  actually had to consider all of these conditions   to be able to deliver Telehealth at scale. And  specifically, video-enabled Telehealth at scale.   So, many of them didn't have EHR workstations  with cameras to be able to offer a video visit   to patients. They also needed to worry about  the platform in which they were going to offer   to patients, which they had not purchased and  used a video platform prior to the pandemic.  

And then they had to completely readjust workflows   and develop new roles on teams to be able to  support patients and being able to do this. And I think those differences in how Telehealth  has been rolled out during the pandemic are   actually also relevant for what we saw pre-Covid.  So, the same way I showed you data pre-Covid   about what patients were doing and how they were  thinking about it, there were also differences by   systems and how they've been thinking about  Telehealth prior to the pandemic. And so,   this is community-based health centers,  so not the large academic medical systems,   but federally-qualified health centers and other  centers that care for some of the most underserved   patients. And a lot of them were actually, again,  prior to the pandemic in 2016, not ready, and  

either about to implement but not ready to  implement. There's a large proportion here   of people who were not already piloting and not  already using Telehealth prior to the pandemic,   and some of the major reasons are  in those workflow and skill-based   situations that I mentioned. So, it's  very parallel to the patient side,   which there's technical barriers, there's workflow  issues, there's a lot of things to work out.  

And so, the fact that we actually offered  Telehealth at scale, especially across   multiple community health centers, is actually  remarkable, given that there was a huge variation   before Covid came upon us to be able to  do this and meet patients where they are. And then, of course, safety net systems  have unique barriers. So, I don't think I'll   belabor this point, but they just really need  products and solutions that are going to work   for their patient population, many of whom speak  languages other than English. The staffing ratios   are smaller in safety net healthcare delivery  systems, and so there's not as much wiggle room   to deliver one-on-one technical support,  to be able to deliver Telehealth at scale.

So, this creates a situation of a multi-level  factorial thing that both patients - it's not   just all patient barriers and it's not just all  provider and system barriers, right. There's   actually many things that that lead to a graph  like this. And the most important thing on this   graph that I think I want to call your attention  to is this light grey bar at the bottom. So,   this is 41 community health centers and safety  net delivery systems in San Francisco in the   middle of the pandemic, and the grey bar shows  how many video visits they were able to deliver   as a part of their overall care. You can  see it increased, but barely increased,   during the pandemic. So, these delivery systems  shifted to primarily audio and telephone visits,   which is the darker blue bar shown here. And  so, when they say Telehealth in these delivery  

systems, it means almost exclusively telephone  visits with patients, without an ability to see   them on the video screen. And they did some  video, but because of these multi-factorial   barriers, they were not able to stand up video  visits at scale, and the way that some other   healthcare systems have been able to. Okay,  hopefully that's not too much doom and gloom,   but I think it is actually the real state  of where we're at and the specific types of   challenges that are there. So, I wanted to focus  the last few minutes just on opportunity here. So,  

if this is the state of Telehealth and this is  sort of where we're at, especially thinking about   groups who might have more barriers on  getting on, where would we move forward? So,   I really feel strongly that technology is going  to get us to a vision of this as the future.   So when I think about my work and health equity,  what I'm really thinking about is the second panel   at the bottom. So, not offering the exact same  thing, like Telehealth or a rollout of Telehealth,   that we assume will be workable and usable  for every person that we're offering to,   which is sort of the top bar, but really allowing  the technology itself to be tailored and flexible   to meet people where they are. And this includes  language ability, digital skill ability,   device variation, all the things that we  know that technology actually can overcome   relatively easier than other modalities.  And how can we get to this as the future? The other opportunity areas -- I just  wanted to underscore this, this is a   busy slide. but the bottom  line of this slide is that,  

again, interest is not the barrier. So in that  same delivery system, San Francisco General,   that I showed you a minute of that did less  than 3% video visits over the entire pandemic,   65% of our patients are interested in doing video  visits. So, again, we have a high interest among   our patients in doing this, and the barriers are  really in those multifactorial barriers that I   showed you earlier, about data and devices and  skills and confidence and being able to use them.   And then similarly, I think our systems are  finally ready to offer Telehealth at scale.   Clinicians in our safety net setting, who faced  many barriers to standing up Telehealth during   the pandemic, still realize and still are likely  to continue both telephone and video visits into   the future, because they realize that this is  the patient-centered and convenient way for many   of their patients to access care. So, we have the  interest. We have, frankly, the change in workflow   and the change in mentality about doing this at  scale. And how can we harness that moving forward?

And then lastly, I'll say, this is very related.  I would say telemedicine is very related to other   things we're offering in healthcare. And so, I  don't want to present this without giving you an   idea that we've learned a lot from patient portal  access. We've been accessing patients to sign into   their health record for a long time now, in some  systems like Kaiser for almost 20 years, and in   other systems at least five or so years. And so,  we actually know that the disparities and the  

inequities in who uses patient portals is actually  very similar to what we've seen in Telehealth over   the past year. That people have to really be  supported with both in-person relationships   with their doctor and digital relationships, and  that it's not a substitute of one or the other,   but actually are likely to be used in combination  moving forward. Patients have to perceive both   the right types of visit to use Telehealth moving  forward, and they have to have technical support   to be able to use it, specifically for those  who face additional communication barriers. And so, I think the last thing that I'll put  out is, we've been thinking a lot about these   frontline experiences, and we've been putting  out a lot of tools over the last year. So,   this is a toolkit that we've put forward on  telemedicine for health equity, that's done   in partnership with an amazing organization  called the Center for Care Innovations,   that works with a lot of healthcare delivery  systems and federally-qualified health centers,   mostly in California but also nationwide.  And so, it has a lot of really frontline,  

so how do we get there, how do we overcome  these barriers that I'm talking about?   It really tries to break down the telemedicine  rollout piece with an eye towards equity.   So at the leadership level, and thinking through  which platforms we're rolling out, how do we   choose the right platforms that are the easiest to  use, that have offered the best language access,   that actually fit into the needs of more types  of patients than all of those who are just   more digitally native and ready to use things  out of the box? How do we support the teams to   be able to do this, to make sure it's a routine  part of their job and can flow into how they've   been trained? How do we support patients in doing  this, which I spent a lot of time talking about.   And then the exciting part, this remote patient  monitoring, helping people support their chronic   diseases over at home. I think all of that,  and what I want to leave you all with today,   is that I think that's coming in the future, but  we really need to be getting these fundamentals   right to be able to optimize these solutions. So,  the overarching strategies from that toolkit are   really using our data more effectively, really  understanding who is taking up these strategies,   which groups are having barriers, and really  meeting them where they're at with questions   that are actually better suited for how to  offer the right modalities. So, whether or not   we're offering a home blood pressure monitoring  digitally-enabled device, or just a video visit   with patients, we have to know that they're  interested, that they have the right devices,   and that they have the right support to be  able to use that device. And then of course,  

I'm being healthcare-system focused here,  because that's where I am and that's where I sit,   but clearly we're not going to be able to do  this by ourselves. There are so many other   resources that we need to be able to do this, in  terms of connecting people to the right thing at   the right time. And these are some really  amazing programs where we need to be able   to have people have access to the devices and  skill-building situations when it's the right   moment for them, and when they're interested  in actually moving to the next level. So, I think that's all. My main talk is, I  really wanted to leave you with a little bit  

of the challenges, just to lay out the actual  facts about where we're at, but hopefully   show you that when we have a multi-factorial  or multi-level view of something like a huge   technology change for our healthcare system  like Telehealth, that we actually can think   about moving the needle, when we think about it  not just being a patient-level issue or not just   being a system-level issue, but actually it's  a multi-level issue that we've made a lot of   strides on, and I hope are going to capitalize  on standardizing this work moving forward. And there's some resources, I'm sure we'll  post the slides. But there's a lot of other   people who've been working in this space, and  I think if you're interested, especially in   the workflow piece, I think there's a lot  to do and a lot to share. Courtney, thank   you very much. We've got a variety of questions  that have come in from members in the chatroom,   and I'm going to move on from the last one and  then go back up. Um, are doctors being paid by   insurance companies by the same rate for video  visits? Is it comparable? And one of our members   says that she sees in her SS receipts that it's  a lesser payment. What's your thought about that?  

Maybe I'll start, David, but I'd love for you to  chime in too. For a long time during the pandemic,   there was an emergency payment that was passed,  so it was covered at the exact same rate as   other strategies. And now we're moving into,  that's what I'm talking about, that next   phase of Telehealth, where I think there will be  different reimbursement based on different types   of modalities. And so, I think you're correct  and that we're moving into that next phase.  

And frankly, there's tons of policy conversation  about what those reimbursement rates are going   to look like into the future, and actually, we've  settled on a few right now. But I don't think that   that conversation is going to be done yet, because  we have to think about the audio-only visit, the   telephone visit that I mentioned, also  video visits, and how they work together   for different specialties and different types of  care. And I think that has forced the needle on a   conversation that frankly, we've been talking  about for decades in Telehealth. And I think   we're actually going to need to be really,  really thoughtful about that moving forward,   if we want to think about the blend of this with  in-person visits moving forward. There has been,  

I could add, a significant effort to try and  extend this payment schedule beyond 2022,   where it's been put at this point. And there's  legislation at the federal level, there's some   at the state level, and it is, as Courtney says,  a strong debate. Because we've seen Telehealth,   while ramped up dramatically,  it has pulled back and plateaued   across all different systems, because people still  do like to be face-to-face. And unfortunately,   the reimbursement side, unless we do have equal  or comparable funds, clinicians or systems may   reinforce in-person visits, because they may, with  our fee for service system, they can gain more   resources or revenue. Versus a program like  Kaiser who has embraced this fully, because   they're trying to do not only good healthcare, but  they're paid on a per capita basis. And that way,   they're being more efficient as well. Has there  been any effectiveness on research to see, um,  

to sort of compare the in-person visits with the  Telehealth visits, the video visits specifically?   Courtney. Yeah, that's a good question. There  has been a lot of pre-pandemic from places like   Kaiser and the VA, the two largest systems that  stood up Telehealth at scale, I would say. And in   those situations, there's a lot of evidence that  the same quality of care is delivered. I will tell   you, though, that it is not as developed as other  research, because there's so many questions about   the use cases that we that we did Telehealth  for during the pandemic, that we were not doing   Telehealth for prior to the pandemic, given the  emergency situation. So there's a lot more that   we need to learn. But the last thing I'll say is  that it's very similar, again, to patient portals,   and sort of sending an email to your doctor versus  coming in-person to your doctor. There was a lot  

of research in that prior to the pandemic. And  what I've taken out of that like, 15 or 20 years   of research, is that it's complicated. Sometimes  when you find a new visit, you find another   clinical issue -- you watch somebody at home and  you see that they might be almost falling down,   or that it's not a safe environment, and then you  want to bring them in to talk about that or to   make some adjustments. And so, just because you're  offering up more, sometimes you find more need  

in the population. And so, I think it's  very difficult to tease those things apart,   and we need to be instead, I would say,  thinking about this as the patient-centeredness   way to do care, which is true regardless of  the clinical outcomes. This is the right way to   offer patients the right modality, and to allow  flexibility for them to blend their visits. And   then we can figure out, I would say, some of the  workflows and some of the differences in nuances,   and allow clinical teams to bring people back in  person, but trying to really realize that this is   the right patient-centered approach, and then  how do we support it moving forward? You know,   I think one of the classic examples that comes to  mind is how many physicians would have patients   coming in concerned about the onset of dementia or  Alzheimer's, and many of those doctors would say,   I watch how they walk into the office. You know,  that everything had to do with their gaits and  

pace and stance and all of that. We, in fact, also  had a project called Gait, where we worked with   undergraduates and OLLI members on developing a  wearable for this. But I think it's a good example   of what you miss by just having somebody face  forward on a screen, you miss the whole person.  

And that might be a downside to being  patient-centric, when in fact what they want is,   they also want the doctor to be able to use their  medical expertise on the full, the whole body. I fully agree. And when I say patient-centric,  I actually think, and I see a chat comment   about it too, I think patients actually want  some input. And I think we're coming to that   new normal of what this is going to look  like. And I think to approach it to say,   it's only for certain clinical conditions, is  probably the wrong way. I feel like it might   put us in a box, where if we think about what  does the clinician want and need and what does   the patient want and need, and then how can we  bring those together, I think that's a much better   way of thinking about what it looks like. Because  I think it's something much more like 25-40%.  

It's not relevant for all visits, but it is  relevant for a pretty large proportion of visits,   I would say, depending on what the needs are  and what needs to be discussed that day. So,   how do we figure out what that balance will  be? Great, thank you. The two other questions   that came in during the time that you were  speaking -- I know you have to leave at 11:15,   and I know that David has a response to both  of these questions, but I'd love your input.   One has to do with cyber security, if you're  having a wired home and you're having a wired   body, and the surveillance aspects make people  very nervous. And so, do you see that as a barrier   to people adopting the technology in the way  that would make Telehealth most effective? Um,   Courtney's on mute, but I'm happy to jump in  on that. And I can say that, very much so,   it's top of mind for all of us. It's critical,  privacy and security is central to all use of  

technology, particularly with our own personal  data, our personal health information. However,   we're seeing a tremendous success in encryption  and ability to protect information, even using   the new, new technologies such as blockchain to  share health information. Is it all foolproof?   No. But we are seeing major efforts put forward in  that area. In fact, what we do see in Europe and  

other countries is a lesser concern about that, as  people realize sharing information, being able to   share your own personal health information with  providers immediately can actually lead to more   prevention and helping individuals. However, it  is an issue, there's no simple answer. I'd love   to hear Courtney's take on it. But it's absolutely  critical, and not only should those of us who are   in this field always put that first, but we think  that it's good for all of us as users to always   be considering that in what we do put in for  information out as we use new technology devices. Yeah, of course. I agree with what David just  said. I would say that at a fundamental level,  

I think the trustworthiness is on us to make  sure that we're doing the best that we can   do with the platforms and the solutions that  we're designing. I think that onus is on us, and   we should reframe the conversation about, do  patients trust into, are we being trustworthy   with how we're doing it and how seriously  we're taking it? And then the second point   I want to make about that is, though when you  think about it from a patient-provider interaction   standpoint, to underscore what David just said,  patients tend to be very trusting about what the   right thing is to move their medical situation  forward, and what to share with their doctor. So,   it's complicated. We think about the institutions  and other levels of it, but when we start from  

a place of, what is the best interaction that I  need to have for my clinical care, I think people   have more openness about what is the right balance  between what we're doing and what the privacy and   security needs are. Great, thank you Courtney. I  think we may have time for one more question, and   I don't know if this is one you can speak to, but  it's about the vision issues, and whether or not   there's technology innovations for people  who are suffering from macular degeneration,   vision, blindness, etc. Is that a question for  you, Courtney? I mean, I could try. I'm not an   expert in that area in any way, shape, or form,  but I will say that we have a long way to go   about with the accessibility of our solutions.  Um, I mentioned language access quite a bit,   which I know more about, which is a real  barrier for the Telehealth platforms   that we've offered. And the ability to add in  medical interpreters who are often used in-person   in the seamless ways into an online format, some  vendors can do that, others have to use the phone,   and then the video for the other. And the same,  I'm guessing, is the situation for that where  

there are existed devices that can sit on top of  your computer to help with low vision and other   issues. But have we optimized our healthcare  system platforms to be able to do that? I would   say we probably have not, is my guess. And how  do we start from a design place of thinking about   patients who have accessibility and communication  needs as the universal design principles for what   we do, is something that I'm really passionate  about, because it generally makes it better   for everybody if we start from from those places.  So, I think there's a long way to go. And because   there's these blend of services, I haven't  seen the industry start from a place of those,   necessarily, in how they've been designing. And we  were obviously doing emergency things during the   pandemic, but I think moving forward, we really  need to shift how we would be thinking about it.   Great. Alright, well, David, we need to leave you  enough time, so Courtney, thank you very much.  

Thank you so much. I'm so sorry I have to  drop off early. This has been really fun.   Well, please consider OLLI as a place  where, if you need to do a focus group,   our members have quite a lot of experience with  Telehealth, and many insights about that. But   thank you. Thank you for joining us today. David,  it's all yours. And I'll add my thank you to   Courtney and her wonderful work, and to give you  that big picture about where we're going in this   space. And you'll now hear me echo many of the  statements and positions that she shared with you,   because those of us working in this field  have begun to see some very common strategies.   In the remaining time, I'd like to share  a more concrete example around Telehealth,   and show you what we've been working on here  at Citris and with colleagues in the field,   and then wrap up with some of the issues,  as Susan has suggested or asked for,   about where we're going next, some of the big  issues that we see impacting not only the use   of tele-technology in general, but how it  will impact us over the decades to come.  

So first, I'll just go back to picking  up on examples that started from our   perspective in Telehealth. Uh, Citris and our  colleagues, particularly at UC Davis, have been   engaged in Telehealth for over 20 years. They  established the California Telehealth Network,   which connects people throughout the state. But  during the pandemic, we were given the opportunity   by an anonymous donor to jumpstart two programs.  That is, Courtney nicely said, we wanted to look  

at individuals who were at greatest risk, who did  not have resources, to make sure that we could   see how we could bring Telehealth, and even more  importantly, the internet, to individuals. We   created two programs, Lighthouse for Older  Adults, where we worked on everything from   not only getting technology in people's hands  and doing training, but how do you even get basic   internet in through broadband, and then again, how  do you make sure people can use this and afford   it over time? We also created a program called  Activate, which has been our collaboration working   with community health centers in Merced, and now  expanding through the Central Valley of California   on bringing Telehealth solutions to individuals,  especially agricultural workers who were at even   greater risk during the pandemic, in creating  new mechanisms to use Telehealth to really   support individuals where they live. We've also  been doing work, as you can see on this slide,   work with other colleagues throughout not only  the state, with West Health down in San Diego,   but looking at major programs that are starting to  really address this issue. AARP recently took over   program Oats, which is a basically a digital  health training program out of New York City,   with the goal of reaching 100,000 people this  year. So we're seeing these major efforts in terms   of starting to address this, both from an equity  perspective and from a societal perspective.  

So, I'll just take you quickly through a few  of our lessons learned as we experienced our   work in the Lighthouse program. And this is a  program that we did not just from the university,   but with individuals and organizations  who are experts in working and serving and   enabling and engaging older adults, particularly  Eskaton, a northern California senior living   organization based out of Sacramento and now  moving to the East Bay, but also Front Porch,   which merged with Covia. Many people here may know  Covia. Front Porch is now the sixth largest senior   living organization in the country. But with them,  we created a program called Lighthouse, where we  

wanted to improve the health and well-being of  older adults, particularly in affordable housing   communities. And the importance here is that, most  affordable housing communities do not even have   internet, much less ability to use technology, and  most residents do not have resources to afford it.   So we created a program, and are still in process,  that started at the end of last year and is now   moving to full fruition with six buildings, to  look at how we could do some of the things that   Courtney was talking about. Doing a multilingual  digital literacy training program done by peers,   evaluating the outcomes, and taking that  program ideally to other organizations,   not only throughout California, but the state.  We created a new way of approaching this. As   Courtney said, it's when we're looking at it, you  need to involve the person who's going to use it,   both a resident as well as a staff person.  And we created a very rapid program last year  

right at the holidays, to reach people.  As you know, many people were isolated,   depression, other issues were critical, and  we created a way to bring internet into the   buildings, provide basic devices, a tablet in  this case, and then making sure they could be   connected. And finally, working with individuals,  including other residents, to train each other.   And we're now trying to reach multiple buildings,  as I said, with many more individuals as we move   forward. So, what did we learn? Well, we realized  again that you do need to engage individuals.   This is the core around technology overall. We  also know that it's going to need, as Courtney  

was saying, the issue of doing it in multilingual  perspectives, the problem with certain things,   Google Translate can be effective. But when you  have, in the buildings we're in, 10 different   languages being spoken, it can be extraordinarily  difficult. So, how do we have technology that   will be able to address these issues? Similarly,  we realize that each person is different. Each   building was different. All of us have different  perspectives on whether we're digital natives or  

have real concerns about using technology, so  we had to deal with those issues. And second,   the digital divide, that Courtney spoke to so  eloquently, is huge. The issue is that these   buildings, the owners often do not even have or  haven't had the resources to put internet in.  

Many of the buildings are very old. There's also  the ongoing costs, who's going to pay for internet   connectivity, particularly if you're on a fixed  income. And you have just infrastructure issues,   it's not just rural problems of getting  the internet and getting broadband   to other people, but we have buildings in cities  that have the worst possible connectivity issues.   So we have major challenges in this space. So,  coming out of this, we're in a process now of   being able to systematize this. We're looking  at different ways to go forward. The key issue   still will be, who's going to pay? So as we look  at the new infrastructure on Build Back Better,   internet is core. And a number of us are going  to make sure that we focus on not just schools,  

not just rural areas, but getting internet to  older adults. And this is going to be critical,   and we're working with a number of federal  and state agencies here. As Susan nicely said,   I'm not only on the state California Commission  on Aging, where we are looking at the legislation   in that area and supporting it, but we're  also working with the different departments,   with governors, a strong support to how we keep  this as a high priority. So again, key lessons,   you have to engage individuals. We need solutions  that can really address the problems and barriers  

for many folks in our society, particularly  in affordable housing, and we need to   be able to create an affordable system going  forward, then one that will be easily accessible.   So, this is a repeat of some of those key  things that you can see on the screen.   Again, just barriers, dealing with multiple  languages, creating new digital literacy   programs that can be sustainable, and making  sure that funding comes as we go forward.  

And I'll just wrap up with a few key points. As  we're looking at all technology solutions for   aging, well beyond those that we've covered  today, I think there's several things that   some of you have heard before, but  Courtney and I would like to reinforce.   There are fundamental issues, and they start with  number one: inclusive design. We must always have   individuals do it at Berkeley and Citris and  other organizations. We have some of the best   examples of organizations working with OLLI, in  terms of how you do include individuals. I can't   say enough about some of the programs that OLLI  helped, really a number of our technologists,   clinicians understand that what individuals  want, we really must start at that point. Second,  

we need to look at digital literacy. It doesn't  matter that we have internet or broadband   if people cannot use it or understand how to use  it. We need new ways to train individuals. So,   I just call out this new program that OATS and  AARP are doing to reach so many individuals.   This is still going to be the key issue,  because the technology is constantly changing   and we have to find ways to help individuals  do it, and in fact make the technology itself   easier to use. And that's where we're going to see  changes, such as more with voice, Alexa is really   getting uptake in certain ways. It's not perfect,  but those are the types of devices, Google Home   and others, that will work in this area. And to  the question about macular degeneration and other  

vision issues, assistive devices overall, but  particularly hearing and vision, are going to   be seeing some major changes going forward.  Just in the last month, we finally heard from   the federal government that they have  approved the new over-the-counter hearing   solutions, which are going to be game changers  for those of us who have hearing impairment. Um,   we are going to be seeing so many new  devices that are just in the hundreds of   dollars instead of the thousands of dollars,  that can be adjusted and be very sensitive   to improving hearing. We hope to see some  similar issues in terms of vision space,   but clearly this is a huge area that  we're going to need more and more support.   And finally, I'd like to close with what I think  is still underlying all of this. And where, by   good fortune, being in Silicon Valley and the  work that's going on not only at UC Berkeley,   where we have now some of the best data scientists  in the world, but actually a whole division of   data science. We're going to see the use of data  and data analytics continue to drive all this,  

because all the technologies we've talked about  require this type of information and how we   use it. So, I use the terminology of "machine  intelligence" to be an overview for artificial   intelligence and machine learning. But we are  seeing some amazing ways to link data together.   What happened, as you saw, in the pandemic  with the results of how we are able to address   issues around dealing with Covid, bringing  in genomic data through Jennifer Doudna   at Berkeley, where she just received again a Nobel  prize, to diagnostic technology -- and this is   where Telehealth, we can do things at distance --  and wearables, and even how social media will be   used to bring information together. So, final  points real quickly, since we're getting close   on time. We have some great opportunities in the  state of California, we are fortunate to be in a   leading state in this space. Our state department  on aging was charged with creating a master plan  

on aging for these next 10 years, and we're making  sure that technology is a major part of that,   and that we will be tracking it. But again,  it's technology as a tool, not as an end and a   solution itself. But in the list I share with you,  these are all the different ways we expect to see   how technology can improve everyone's well-being,  but particularly those of us who are older,   and we will be working on that to really make  sure that our state and both public and private   puts that first and forward, as we go forward. And  the last example was created this year: the idea   of a single, common database that will be able  to share information. And this is the fact that,  

as you all know, all of us get information or need  services or participate in all these different   areas, but information currently cannot be  shared, and can be very different, and we do not   have the benefit of having all that information,  particularly social determinants of health. Well,   state of California a year from now is challenged  with trying to create a connected system.   So, stay tuned. I'm on that advisory group, and  I'm very intrigued to see how we can do that. But  

again, it shows what we can do in this area, and  some of the benefits that we expect to see in the   years to come. And with that, I'd like to thank  you. And I know we only have a few minutes, but   we will also be available, Courtney and I will  always be delighted to speak with folks and work   with Susan and OLLI to answer any of your  questions. David, thank you very much. This   has been just chock full of information. And you  know, around some of the innovations and some of  

the other issues that are political as well, one  of the things I just want your personal opinion   about, is that so much of this is  requiring an infrastructure. And   how do you regard, has the private sector stepped  up in the way one might imagine, or do we need to   ask more of the private sector? Um, so that some  of these really huge issues around the internet   and around digital literacy have the benefit  of a private-public partnership. What's your   thoughts? That's a great question, Susan. And  as you can imagine, I think industry has been   very forceful on this. We're seeing dramatic  changes, particularly in the issues around   reaching older adults. And with technology, it  has been a game changer in the last year. Amazon   just hired one of our colleagues who is really  leading the charge in that space, we're seeing   a new attention in that area. Obviously, there's  a financial interest, it's a business interest,  

but that in turn is helping bring this to more  individuals. On the other hand, there's still   disparity, we have this digital divide on all  levels, and because it's a business decision,   often there are a number of individuals who do  not have have that. Furthermore, while there's an   interest and a support for this type of training,  that's still been secondary at this point.   I think what we're seeing is a combination of  public sector and our government, and particularly   with the potential for the huge amount of  resources that could go in to help build out the   rest of the internet, particularly the last mile  getting things to individuals, and there will be   along with it the need for this training, we'll  see a greater push there. And I think again, we  

will see, there'll be a push-pull from both areas.  But I found it amazing how there's much greater   interest. And I think we will all see, it's a  silver lining, if there is one out of a pandemic,   that this has opened the door for a number of  these. As we said, it's not just Telehealth,   but it's all these other ways that we need to  look for solutions where technology can improve   things for all of society. David, thank you. You  are a most valued colleague, and I look forward  

to the year ahead when we begin our planning for  the Aging Research and Technology summit with our   colleagues on campus and within the UC system.  I want to thank the members who came today, and   I think we're all much better informed. We're  still skittish about the cyber security issues,   I think many of us look at what's  happening with the European Union   and some of the regulatory  things that they've put together,   but at any rate, we are moving forward. And thanks  for helping us take those next steps. Thank you.

2021-11-12 08:35

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