 Welcome everyone. I'm Steve Clemens. I'm editor at large of the Hill and it's a real pleasure to be here today. Really performing facilitating role on behalf of New America's Health Innovations Lab and its international security program. Our topic for the day is to discuss the future of health care in a post COVID world. We have two of the most outstanding thinkers and commentators we could have on this first we have Dr. Rear Admiral Susan Blumenthal also Dr. Dr. Health Innovations Lab and she's a senior fellow at Health Policy at New America. She's a former U.S. Assistant Surgeon General former first Deputy Assistant Secretary for Women's Health the first one in that role. She was clinical professor at Tufts in Georgetown University Schools of Medicine and she's a visiting professor at the MIT Media Lab and she's a good friend of mine. It's a real honor to be here with Dr. Blumenthal and then we're honored to have Dr. Shantanu Shantanu Nundi who is the Senior Technology Advisor for the World Bank Group. He's also Chief Medical Officer at Accolade. I've spent some time reading this book that he's just done I'm going to show you a minute and like it's written like quick chapter after quick chapter and I think in between each of these he was seeing patients and people and doing things. So you know he's very frenetic and it kind of comes out in this but Shantanu's book is called Care After COVID what the pandemic revealed is broken in healthcare and how to reinvent it. It's just out two days ago. Let's send it to the top of the New York Times list. So let me just open our conversation we're going to talk and and I've been told that all of you will be able to post questions which we will get into as well. Let me ask Shantanu just to sort of help set the stage for a moment in this and when I read a book like this. I have a lot of aha moments and that makes sense that makes sense. I understand that that that the COVID experience has transformed telehealth people have really gone. We used to talk about going from the analog world to the digital world. In fact that's been a new new America obsession for two decades but it's really happened now. And I guess my question to you and I've always feel this even when I was at New America many years ago. Are we reacting to circumstances or are we proactively thinking about them. And I have to say that I'm not sure reading your book we're at. Are we reacting and now we're going to end up in a better health ecosystem because of the COVID experience and that's a reaction or should we have gotten a lot of this right before COVID came along. Let's start with you and then we'll jump to your Admiral Blumenthal does that does that sound good. Yeah, absolutely. And first of all thank you so much New America for having me Steve Dr Blumenthal such an honor. We in my opinion were absolutely reactive right I mean there's an old saying necessity is the mother of invention and I think that's what we've seen right we were in a once in a century pandemic and that's what pushed us really to make changes changes that I think folks like Dr Blumenthal been talking about for a couple of decades. But we had a whole host of reasons for why we didn't do it right we said oh well, virtual care can't be, you know, can't be done there's different workflows, payments very complicated there's privacy issues right but what I saw in my clinic I still get a chance to practice like you said at a safety net clinic is we went from zero to 80% virtual in two weeks and never literally never done a virtual visit before to now it's the way I'm providing the majority of the care that I'm doing today. And I think we showed ourselves that healthcare can be way more flexible in a crisis than I think most of us thought. Well I'm going to go to Dr Blumenthal because she and I have literally been talking for years about this the reason I wanted to start with you is to get this notion reaction because she was thinking about this way before COVID. So I'm just to ask you, Dr Blumenthal Susan, why were we so poor at making some of these platforms and decisions and the nimbleness and being able to meld, you know, conventional needs in healthcare with some things that we've seen because I know you have been thinking about this a long time, you didn't need a pandemic to get there. Right, well thanks again Steve for for moderating this discussion welcome back to New Americas the founding executive vice president, you know we're so delighted that you're here and and joining us to talk about the future of healthcare. You know, I think the father of medicine Hippocrates once said prevention is preferable to cure. I served for two decades under four presidents. We worried about anthrax while we were faced with anthrax we were faced with each one and one flu. Each time we're reactive, we'll spend anything once there is an issue, but we don't build the resilient public health infrastructure that's needed. We don't we don't invest in prevention you know we spend only 3% before the pandemic of a $3.5 trillion healthcare budget on government prevention programs. We let the pandemic you know after the Ebola, we let that pandemic office atrophy, and we let our global connectivity atrophy. I think that the pandemic you know showed multiple weaknesses in America's public health infrastructure you know there was no real time data surveillance. There was, you know, a lack of testing contact tracing public health communications, you know we saw that a vaccine availability and production and distribution had not really been thought through on what would happen on a mass scale. And at the beginning of the pandemic there was a lack of a dearth of mass and personal protection equipment and, and this myriad set of websites that, you know was like the hunger games with people trying to find, to find a place for vaccines. And I think that this is just was reflective of the fact that we weren't thinking ahead, and that we weren't modernizing our healthcare system using digital, you know technologies, we also saw a shameful set of disparities that were not all too long in our healthcare system, but the pandemic shown a spotlight on it in terms of blacks, you know Latinx and indigenous peoples having two to three times the infection and death rate has compared to whites, and showing that not only was there, you know a lack of modernization of the public health infrastructure but also structural racism that existed and an urgent need to prioritize equity and inclusiveness in the in the design and implementation of medical interventions. So, I think a lot of these deficiencies were exposed and, and, and now is the time you know we have to race to fix them. Before I jump back to our author of the day, Susan. You know I've, I hate to talk about medical people in any partisan sense but there are some like Dr. Redfield the former head of the CDC. who who works under President Trump but also many Deborah Birx was an advisor, but I have interviewed. Dr. Birx Dr. Redfield Dr. Fauci, you know, celebrities like yourself Lena when others, and it doesn't matter all of them said that our under investment in public health infrastructure was a chronic and glaring red flag for a long period of time. And I'm just wondering whether the passion and drama and needs of this moment are going to fix that, or whether you worry that the moment we begin to see the light at the end of the tunnel, we fail to invest again. I think it's it's always a worry Steve thank you for raising that I don't think though we can let this happen once again you know if you think about it, I mean United States is 5% of the global population. We had 20% of COVID infections, 18% of the of the death rates. How could a global leader in medicine and technology have lagged so far behind in an effective response to the coronavirus until recently. I think that the what has happened though this era of past neglect has really mobilized multiple sectors of of our society policymakers, technologists, public health professionals and medical experts to really re examine the system. And, you know, to, to move forward I mean we've seen already, you know the reinstatement of the CDC as a as a premier institution. We've seen the re establishment of the Office of Global Health Security in the White House that had been disbanded. You know, putting top notch people into positions across the government, but we have to make sure that the money is there that we were not just you know always begging for public health money but that we are really making these commitments. And I think you're going to see a lot of, of, you know, pressure because as Mark Twain said, history doesn't repeat itself but it tends to rhyme, you know, we have people forget that infectious diseases have killed more people than war, and we have to remain vigilant against them. Thank you Dr. Nindy one of the reasons I liked your book so much is that it was clear that you're not only a health policy wonk, but you're out in the field you see people, you have a health care practice where you see people in the safety net and the greater Washington DC area. As COVID hit, I'd love you to kind of give us the highlights of both the, I hate to put it this way, but the good and the bad of what you experienced as a practitioner what people, real human beings were experiencing both it was good. And that was in that were clear deficits in our health care system. Yeah, I love that question I think it's so important to orient that way I mean I think, look, I've had the privilege of working in the safety net for almost 10 years now. And I'd say that, other than launching a patient portal a few years ago, I mean, it really has not changed. And, but during the pandemic, I only get a chance to practice once a week so it's like you know you watch your grandkids grow up, and you get to see them like every three months and it was like that for me, going to the clinic once a week, it was incredible to see the right from literally it was a waiting room full of people to a completely empty one we're all virtual to come back two weeks later we have a white tent, and we're swabbing people's noses in the white tent to a few weeks later we're starting to have just a subset of patients be able to come back to we're handing out blood pressure costs that people can drive up, we would hand them a blood pressure cuff and bag and say hey, we're going to measure blood pressure from home. The level of change we've seen has been dramatic. And I think that it's been really positive in so many respects right you talk about virtual I mean virtual was great because care became contactless right and that was important to event, you know, people from spreading infection. But guess what, I saw my no show rates in my clinic meaning patients that would have an appointment and couldn't make it drop from 15% almost zero. And why, because for someone who's living on the margins to be able to take a half day of work off, which means that they're missing their wages that day and finding childcare and getting transportation. Those barriers were so, so significant that simply making the care, the visit with me virtual allowed us to bypass that. And you can see how that's beneficial not just for COVID but for chronic diseases. Another great example is the way we use data so we invested in electronic medical record years ago, but we weren't really using the data, but when the vaccine came out and we had protocols to say it's only eligible for these people and then those people and those people. Guess what we had to do. We started combing our data to find people of those different risk levels and calling them up out of the blue, so not waiting being reactive waiting for them to show up and hoping that they show up. And then calling our patients and saying hey, you know, we are, we want you to come in for an appointment because you're identified at being high risk well guess what. That's something that we could use after the pandemic to find people who haven't come in for their diabetes per year or people who recently been in the hospital right that muscle of taking data and being proactive was big. I was meeting people where they are like literally, you know, so going canvassing door to door step to door step in the community, getting people registered for the vaccine, making sure that they have food. All those things are real muscles that we've built. The sort of the way I say it is the way that care has been architected itself, which has been completely concentrated in clinics and hospitals we've re architected care to be much closer to where people are. And so there was a lot of those positive things I think the negative things, the short version of is we already know all those things. Right I mean those things again like, you know, Susan said have been magnified or accentuated. But as a physician, I mean I've been seeing that stuff for a long time, and it wasn't a surprise in some respects to see those things persist. Well I'd like to echo what you know Dr. Nundi is saying because I think that you know for for some of us as you as you mentioned early on in your in your introduction Steve you know we've been trying to to think about ways of modernizing and re engineering the health system you know using technology. But the, the coven pandemic accelerated the ability to do that you know it put yes a magnifying glass on the myriad faults in America's health care system. In excess ability to be inaccessible on affordability it's an equity it's fragility but as Dr. Nundi said it also revealed just how flexible the system can be in the time of a crisis so this once in a century, you know public health emergency has ushered in a once in a generation, you know reimagining of health care delivery, virtual care digital services that may actually improve patient experiences and build more resilient public health infrastructure. As Dr. Nundi said, not just for the pandemic but for the other health challenges and there are so many that face us now and in the years ahead. One quick thing which is, I agree with everything Dr. Nundi and it's not just technology either because a lot of people out there is saying well hey, you know, not everyone has connectivity and device and all that stuff is true, and then magnified again during the pandemic, but it's a lot of non technology things like the drive through. Why is it for the last several decades we get people that are sick and coughing and sneezing, putting them in a place we literally call the waiting room so you can get a text, right, so the drive through which is literally like a white tent with a nurse standing there with a q tip is not a piece of technology but it's an innovation that's been sorely needed right mass vaccination we know that we don't vaccinate people for shingles we don't vaccinate people for the pneumobax, the idea of vaccinating them in their homes and churches and mass vaccination sites. These are all sort of non technology innovations to that. I think we've seen truly scale during the pandemic and now again the question is, what do we do with all that. You were at the beginning of the book trying to talk about how when you were assessing what you were seeing in the early stages of the pandemic, how to set up a plan you did this bit with Kavita Patel on how to you know encourage home testing. I mean I think one of the questions I want to ask I have a second one for you, Dr Nundi but but how hard is it to get the health care system to be logical. I mean because I sense your frustration at the beginning of that here was an innovation was processed it wasn't ingenious it was pretty common sense, but you had kind of a, you know, difficult time with it. I'll just double click on the story a little bit I mean yes, you know, back in March we'll all remember that first month everyone was obsessed testing testing testing testing. A colleague, Dr Kavita Patel and I just were on a phone call we said gosh, why can't people just test themselves at home, and wrote a piece about that. I mean the public interest and the interest amongst doctors and patients was enormous. But when we went to sort of the powers that be broadly speaking. Yeah they had so many questions they said well, how are patients going to know like when to get themselves tested they're going to overuse it I said, really, people don't have money to burn and they're not going to people don't enjoy sticking q tips in their noses right. So how are people going to know how to do this. This is really hard only only doctor can only help her professional because this is a really, because I remember when I was a medical student, and a nurse showed me how to do one said go to the next room and do that. That was all that was all the training I got right and with the ability to watch YouTube videos and like come on people can learn how to do this. And, and then the last one they said is how can people know the results of the test themselves. Oh they'll have to understand sensitivity and specificity and how are they interested. And it was, and so yeah it was frustrating, and frankly, we missed a very very important window, right. As the pandemic was was really hitting us hard here to have a much better model, a uniquely American model we get everything mailed to our house and Amazon boxes these days why can we get a test. And of course now, this is not a commercial for any particular company but you know my mom flew back from LA she's back to me we're back to me that she came home two weeks ago. She came home from the flight, my grandkids aren't vaccinated my kids are young, and on our kitchen table for $14 she swabbed her nose 15 minutes later, she got a result was hugging her grandkids, right. And yet we heard these stories of people spending over $1,000 to see a doctor and get a test $14, you know people can test themselves with a pretty accurate that these are the. Again, because I haven't seen that before. I don't care, you know, go ahead and ever you can walk into any for Walgreens and get this Abbott labs okay great. Yeah. And another example, what was the web was the website, I mean, I built the first website in the government for health. I was going to get to that yeah. And it's like, you know, we, again, there was a lot of resistance of NIH CDC had nothing online at the time we had to build it at the Department of Defense to create a one stop. You know, and so fast forward. Here we are again. There's a Byzantine series of websites, people can't, they have to wait in queue on on the line to find you know a vaccine site. Why didn't we build immediately, you know, a one stop shop for health information, a way to sign up for a vaccine to be in queue and matched in your zip code with a 1-800 number if you can't navigate the internet. But it's only recently within the past few weeks that such a system is coming into place. That's just inexcusable in the 21st century. And I think it underscores the need again to plan ahead to have the capability of bringing public health and technologists together because if we're going to redesign and reimagine a modern health system for the 21st century. You know, we really need to work together, and it's not just technology. It's it's marrying public health science and technology together to create the kind of responsive, effective, efficient healthcare system we need in the 21st century and that's why I'm working to with a number of groups to try to create a new field of public health technology that will you know, create a new generation of technologists mean many who've gone into business world entertainment, worked in the biosciences but we need them in public health. We need this generation that's been inspired by wanting to act and respond to this pandemic to help us with the other health challenges that are with us today and tomorrow. That's terrific. I really want to hear more about the Center for Public Health Technologies or initiative it's a. I'm fascinated by how quickly things have changed I think that's what Dr. Nadee was outlining this book, but let me ask you another dimension a few days ago, I interviewed someone you know well, Susan Dr. Senator Debbie Stabenow on mental health and she she reminded our audience that you know your health above the neck is as important as health below the neck and in your book you talk about mental health, and you talk about this dimension which is often neglected in public health discussions and personal health discussions as something that's gotten a real boost in terms of the digital and technology platforms and telehealth that perhaps was unexpected can you tell us more about that Dr. Nadee. Yeah, absolutely it's such an important topic as you said I mean, it was really a multiple dimension the one so part of my life is I'm chief medical officer of accolade it's a company that serves employers. I saw you today compared to a year and a half ago, I seldom walk into a room with an employer, or mental health wasn't isn't the one the top one, two or three things that they want to talk about. And that's, that's a massive massive change for what it was before I think a testament to the broad awareness and magnification this grounds well that we have and say, Okay, well now what do we do with it. And that is, I think what we learned and I'll tell you myself. One of the first patients I did a video call if I do a lot of audios look the first video call was a woman who, as soon as I got her on the video I could see she was terrible. And I looked at her everything I said, I think you work here. And she did she actually worked at my clinic in a sort of ancillary role, and, and she was careful and she was telling me about how you know she had a new baby she's a single mother. She couldn't go and normally help but she couldn't because of the sheltering in place but that she dealt with depression after her first baby as well. And, you know what I realized was, you know, at first if someone told me hey you're going to take care of someone who's tearful and an emotional over video I'd say no way. That's when you need to be at the bedside that's when you need to hold their hand. But as I saw in this conversation it's kind of like face time if you face time with your family members it's very intimate, actually. And it wasn't me in my white coat it was me in my own house with my own messy scribbling walls, and it was her in her home. And I also realized logistically right this is a new mother who had to juggle you know the car seat and she also was someone that worked in my clinic maybe she would face a lot of patients with mental health face stigma maybe she would face even more because her coworkers were like hey what are you doing here oh I'm just here to see the doctor right and I realized in that moment that had it not been for for virtual we may not have had the opportunity to even to be with each other, let alone create that sort of close connectivity that in a strange way technology can sometimes do not always. I mean because for most people with mental health we know that therapy is a very proven intervention but that's a very hard intervention to do right you're seeing someone one or two times a week for for several weeks to months. How does that work for for most even, you know, privileged, you know, folks who have flexibility in their schedules let alone for people who whose jobs don't offer a lot of different options and so, you know, at least in that moment, I saw and I saw many people spend really the opportunity that that virtual has particularly in mental health. And I think you know Steve thank you so much for raising that issue because you know one out of five Americans suffers from, you know, a mental disorder and any year period and the rates in the pandemic by 40%. So, you know for and I think you know Dr. Nundi, you know, rose some of the issues like inaccessibility, where do you find a therapist. How do you get there childcare issues transportation issues so for our rural and underserved communities. I think virtual services have made a real difference and, and I think that being able to check in with someone frequently. For example, woman may have postpartum depression, but she's juggling her baby and she doesn't have childcare and she can't get in but you can check in on her virtually and see how she's doing. And I think all of these things have come together. You know it's also a source of support, having support groups online. I think that you know the brain is a great orchestrator and it gets sick just like the heart or the pancreas for diabetes and it manifests in our behavior and, and I think you know this integrated system of brain and behavior and health have to be one and I think the virtual world helps us with that. I'm going to tell our audience to keep sending in your questions because I may go to them earlier which I'm going to do right now because somebody posted a question that I want to ask Susan and Sean to new. And the question is how can we guide policymakers to continue what works regarding telehealth and other issues and I think this is one of the interesting questions and I want to lose our audience but one of the most controversial important topics inside the health system is payments. And so telehealth is is covered right now and there's a lot of concern that you know some of the innovation some of the things we brought along. You know as we get beyond the pandemic, we may go back to conventional patterns that may not have the support and the payment system supporting telehealth Susan, how do you see that do we have to worry about that or is is the progress that we've made in innovations like telehealth solid enough that policymakers will not be silly enough to roll that back. Well I think we do need to remain vigilant I worked with the DoD two decades ago trying to push telehealth services and get reimbursement for it but there were trade issues because physicians and other healthcare providers are licensed by state. And there is a mechanism that's been input put in place that allows you to be licensed across states, and this needs to be expanded and given the support that it needs. I think also you know we need to have outcomes research, we need to make sure that virtual services work and we need to have the outcomes that will make the justification for continuing the payments that are needed. You know Medicare, you know loosens its payments at the start to provide payments, we need to make sure there's parity. And I think that again policymakers will need to have pressure and keep the pressure on and I think consumers have an important role to play in lending their voices and letting their policymakers know that virtual services helped and that they should be sustained. I'm going to ask you the same question but I'd also ask you to reflect on the dangers of going too far one way there was a section in your book, where you talk about, you know a patient that a lot of you know people could do telehealth they can you know had symptoms you could sort of sort out whether people generally should be tested and whatnot, but there was a patient whose oxygen levels were so stressed that if that patient were there that patient might have died. And so there's a that there is occasion for in person visit so I'm be interested in the trade offs as you see it. Did we lose. We need to go for hybrid care you know I mean replace the in person visit. That's not the goal. It's really to create a hybrid model that both the patient and the healthcare provider. Dr. Nundi I see you're back. I am I apologize but yeah I was going to speaking of virtual care. So I was just going to make to you know somewhat provocative comments right I think the first is. Because I worry that we're going after telehealth a little bit too narrowly. Right, I think really what we need to do is there's this common principle that I think Susan, I think you would espouse as much as me which is, we have to meet people where they are at home in the community at work and online. And that's really what we have to do but we have a payment system that is location specific. I mean look if I see a patient in primary care in my clinic, why should that be different than if I see them in their home. If I can hospitalize a patient in a hospital. Why shouldn't I be allowed to provide hospital level care for that patient in their own home. Or if I'm seeing someone high blood pressure why should I not be able to see them and get paid just to take care of their blood pressure in a barbershop if that's where they feel comfortable this idea that where the doctor is is somehow connected to whether we get paid which means whether we can do it to me is just is absolutely an acronymistic and and just like in telehealth we need to open up this idea of being agnostic to place a service. The second sort of provocative point I'll say is that, you know, we can't just take a pretty not. I mean look let's be honest most of us that go to the primary care doctor even a clinic, it's not a great experience. Right, it's the visits are 10 minutes and they don't really have time to they'll interrupt you within 45 seconds and then you'll leave and you don't hear from them oftentimes for two to three months. What we can't do is waste this moment and wrap and take what's a largely broken experience in the real world and make that a largely broken experience virtually. Right, what we need to do is say okay now that we have the ability to connect with the virtual how do we just reimagine the whole thing. So example I give is my mom, who's been has had type two diabetes for 25 years and it's been uncontrolled for 25 years, and she's been on insulin for 10 years with just increasing doses. During the pandemic, she completely reversed her diabetes, meaning that her sugar is controlled and she's off of insulin completely. And how did she do that. Well, it was a virtual service that she signed up for, but it wasn't just again taking an in person visit every three months and making it a virtual visit every three months. So she was given a 24 seven coach, she was sent recipes to her home. She had a glucometer that sent data. She was connected to another patient like her who's from India and vegetarian, who could share other tips and tricks that he learned for how to maintain the diet that she wanted to follow, right, to the point where a month and she lost 15 pounds and got up events completely like that's what we need to do we need to take this new, this new possibility and say, how do we need to deliver care differently to Susan's point so that we're actually getting outcomes. And I think that's really, really, really critical because remember, and I want to underscore what, what Dr. Noody said is that, you know, here we are with some of the most advanced science and technology in the world. But did you know we rank 42nd on life expectancy in the world, we, according to a random report we get the right treatment only 50% of the time. We have to virtualize that experience we have to use this pandemic as an opportunity to reimagine redesign, and we engineer a health care system so that it works better for doctors, patients, and the health care system. Susan, how do you do it, I mean, and I don't mean to be facetious about it because I know you're an innovator, particularly in the policy space and government. But when I just listened to Shantanu describe the, the wraparound connectivity that his mother got and how I see it happening and various stuff I'm doing right now, get out and run you know who I'm running with find somebody we see that in, you know, Peloton and others is that that these new platforms are being created. But I just sort of feel like the government is a bit of a lag factor in these issues I remember, you know, and this just to be silly but in a new America board dinner once in the Bay Area many many years ago. And the topic was how Silicon Valley could help end death, and someone of the Washington type sitting at the dinner said that's going to be terrible for entitlements. And so you kind of saw, you know, here's this notion that there's this innovation space out on the West Coast, and Washington regulates and Washington is behind. And I'm just interested in how you think when you're talking about this cultural shift and change, we can bring government people along so that they don't impede that innovation that they help drive it. Well, again, I think a really important point Steve, one of the things I've been working on at New America is how do you modernize our federal food assistance programs for example we saw during the pandemic one out of six Americans is hungry. Well you had a food system 53% of all infants are enrolled in the federal WIC program. Yet they were getting a paper voucher, you know, to give their benefit which had so much stigma, and you lost 68% of people by the end of, you know, a child's fifth year when they're eligible so you know how do you modernize that program with with technology and I think the pandemic accelerated it, it's starting to permit online ordering or pick up at the grocery store rather than having to go in and shop. You know, and, and so I'm just, I think that this acceleration of the way we're thinking, and the redesign is, I hope will permeate, you know, our centers of innovation at Medicare, the HRSA system, and all of our federal programs will be facing a redesign so that they work more effectively for the 21st century and policymakers I mean, it's a stimulus response organization and so if they're stimulated by the consumer saying this is important to them. I think you're going to see more innovation in the system moving forward. Dr. Nindie, let me ask you about the state of our medical records today inside health systems and whether they are designed and compatible with each other enough so that all of the things you're talking about in the digital space from research to knowing how to personalize healthcare around someone, whether or not, you know, I'm just going to tell you right out because I don't think our health record system is up to that that standard but I would like to love to get your view. And if you agree with me that there's a pretty crappy situation of the healthcare system within health systems, what can be done to change that so that the world you and Susan are describing can can get a turbo boost. Yeah, no I love that question and I think first of all I think for folks that you know, it's easy to think okay the electronic medical record that's like seems like really minutiae, but the reality is that piece of equipment or software drives what doctors do and don't do. Right so like when Susan talks about 50% of treatment decisions that are made or are not the right treatment decisions. We're keeping that information we're ordering that prescription in the electronic medical record. Right when we meet with somebody and we don't recognize that they have food insecurity. A lot of times that data may exist somewhere in the electronic medical record but it's not hitting us over the just for everybody out there I think just the electronic record is really the most scalable way to change the behaviors of healthcare professionals and patients. And so it's a super important topic and the short answer is no. You're like what we did largely is we took up a paper chart, and we scanned it for like $100 billion. And we said here's your electronic medical record. I mean I can't even do simple things like if you said to me okay, I should be able to like Gmail search in there to say find me all my patients with diabetes that's not controlled enter create a list. I can't do that today. And it should be interoperable I mean you have hospitals and patient clinics within one you know university setting that they don't interact. And, and again another key element is that it's going to be very accessible for the consumer. So that the consumer has access to their information. And we also have to make it equitable you know, well, many people on, you know, under incomes of 30,000 use the Internet. We see, you know, many black and brown communities rural towns and elderly facing the triple threat of a digital divide they have lack of broadband connectivity lack of mobile devices and lack of digital literacy. So post pandemic this digital access will increasingly will equal health care access so as we're talking about the President's infrastructure plan, we have to make sure that broadband access, you know, is part of that because as I said I mean and as we're talking about as digital services become more a part of it, and well designed ones. We need to ensure that people have access to it. And I feel like gravity is going in the right direction now as regard to that because, you know, I, I saw firsthand in CVS clinics where I was getting my coven vaccination that no I saw on there for again it's an older elderly black gentlemen, telling the young clerk. I can't get on the internet I don't know how to get on the internet I try to call the 1-800 number there but I would have given up my mind if I, I would have just to take this person now and bring them in I sort of feel like we're talking about broadband connectivity. Here's somebody walking I sometimes feel like that individual who's trying his or her best, who is from one of those marginalized communities still trying to get over it. It's somehow our system hasn't figured out how to be effective and have heart. I think I think that's a right and such an important point I mean, we have to have hybrid models. It's not all digital. It's not all in person, there needs to be a way that everybody can access that we're when we're designing we're thinking about all communities, and how various, you know, marginalized groups of people are people with who don't have digital I can can access the system to and how we can find them and I think that's also what Dr. was talking about about bringing care to the, to people, you know people were going door to door to help identify people who hadn't been vaccinated are healthcare providers I think 1-800 numbers are useful but let's make sure they have enough operators so you're not put on hold for two hours. And, and I think, and make sure that they're in multiple languages. And I think that these are things that we must demand going forward to make sure that things are designed for everyone to be comfortable. Yeah, I completely agree with everything and I would say that we have to start measuring the experience of care. Right. When I got to my current role at Accolade, having been in the healthcare system for a long time. I was in meetings that kept saying ASA, ASA and CSAT and CSAT and I thought oh ASA was like aspirin because for doctors ASA is like a root. It means average speed of answer. And CSAT is customer satisfaction we measure at the end of a lot of our calls or satisfaction just like you would do in a lot of other industries, but not healthcare. Right. And so when we talk about moving to value based care which is a super important effort. A lot of the way we're measuring value though goes back to the sort of the measures of quality that, you know might matter to a doctor to a health system, but not necessarily the ones that also matter to people like I think that story gave Steve so poignant. The question is how do we just, you know, like Nordstrom put everything aside and say sir, I'm here to help you. How do I just make this easy. But if we don't incentivize that in the way that we pay for care and the way that we measure care. I don't feel like people are going to be on today at where I work, a portion of our dollars go back to the customer if we don't hit our satisfaction and ASA targets, we have to literally give money back. I love to see health systems have to give money back when they don't treat patients the way they should be treated. I also think Steve, you know your comment really underscores something else that we need to think about in medicine, the intersectionality of issues that the socio cultural determinants of health. One third of deaths in our country are linked to issues like poverty, lack of education and structural racism. And so, as we go forward and we think about redesigning the health care system. You know, you can treat someone in the hospital but you send them home they don't have a place to live. They don't have adequate food on the table they don't have transportation or childcare. You can leave them back in the hospital within a week or a few weeks. And, and so when we're designing when we're redesigning and reimagining this health care system we have to think about these other factors addressing the inequities and inequalities that have existed in the health care system, making sure, you know that housing and food security that they're all part of the way we think about health care in the 21st century. I really example on that real quick, Steve, if you don't mind like how to do that because I think it's absolutely how do you do that. I remember this patient of mine who was in and out of the hospital with heart failure. And one of the things that you have to do to prevent heart failure is you have to check your weight and if your weights up a couple pounds, you take another, you know, extra dose of medication or call your doctor. And all these hospitalizations I was talking to this patient I said, I said, you know, remember, check your weight every day, and then I left the room. And then as soon as I left I thought, what if he doesn't have a scale. So went back in I asked her that, do you have a scale. And she was very embarrassed to say no doctor I don't because I can't afford one. And I looked around the clinic we didn't have any extra ones I gave her $20 on my pocket, which by the way is is like again some sort of rule. And, and she never got admitted to the hospital again. And this is the idea that look if I wanted to order her a CAT scan for $1,000 I could do that if I if I wanted a hospitalizer and run up a $10,000 bill of a cardiac catheterization and a treadmill test and three days and I could do that. But if I wanted to give her or wanted to get $20 for her to get away in the scale, I can't do that. And so I think the way to do that is, rather than a block broad blanket programs, which is most of the way that we're building policy. What we should do is say how do we give more resources to the front lines to the people who are actually with the patient to say hey this one needs a $20 scale. This one needs a transportation voucher using lift or uber. This one needs, you know, a place, a place to sleep at night. We're the ones in the room with the patient and understanding what they need. Give us the resources to make those determinations. And when you do that what we saw if you look at clinics like Oak Street in Chicago, who actually get resources they get a large share of the premium dollars for their patients. That's how they're financed. Amazing things. They went from taking having mobile vans that brought patients to their visits to they turn the mobile rounds vans around, and they started delivering food and medications to people's homes. And so, rather than this kind of one size fits all saying well everyone needs virtual or everyone needs this or everyone needs that. Give the resources to the people closest to care, and enable them to be able to decide how to allocate those resources to solve those core barriers and challenges our patients base. It's really great framing that you brought to this and I'm so happy, Susan that you talked about the systemic racism in the system I remember when I was at the Atlantic my colleague Olga Kazan wrote an article about the Baltimore area and the 20 year life expectancy difference between different parts of town, and that you could look from one other so we did a big health forum there. You know when spoke at it we had lots of health pubas come in lots from Johns Hopkins, but what you really got and we brought in real people who were trying to navigate that health system from these marginalized communities. And it became clear is there are a lot of earnest people who wanted to do better but you could feel the cards were stacked against them and you could feel that they felt that those institutions were indifferent towards them. And there was no social trust, they didn't see black doctors they didn't see black interest they didn't see themselves in the system and so there's an absence of of trust at that at that level, which I think is going to require somebody to take 20 bucks out of the pack and say hey here's a scale. Now I'm just sort of interested. I mean, I know we're talking about what we can deal with, but to change gravity and some of the worst places in the country. You're going to have to get institutions to behave differently. Your thoughts on that Susan. I think that's absolutely right. I mean, you know, it's shocking you don't have to go to the developing world to find a 20 year life expectancy differential. You find it in in a city like this and in communities across America, right here, right here in the United States I think that trust is one of the most important factors, we're seeing it with vaccine hesitancy in the sense that you know who is the influencer that is going to help you and how do you involve communities in the design top down does not work. So if we're going to affect change we need to bring in community advisors, and we found with, you know, we're funding in in Africa through the President's emergency plan for AIDS relief community health workers, you know to go around and to someone like you but a little bit wiser who brings you information and, and helps create a local system of care. We need that in the United States of America. We need community health workers who are empowered to help communities to build the trust and build relationships between the health care universities and academic centers and the communities which they serve. Great. We have a question from the audience. For both of you says an influential primary care physician Margaret McCartney recently tweeted, how providing remote care is harder feels riskier, less chance to build relationships. This telehealth contribute to physician burnout. It's a great, great question I think that the answer is it depends on how it's designed. Right. I mean I think look in the worst case scenario, the worst kind of telemedicine we can do right is audio only. You address the patient's acute issue which is you know their sinusitis or their back pain, and you tell them to go get a prescription somewhere else, and you hang up the phone, and you don't never follow them. That's not what we need. Right. But if you can actually create a space, you know sometimes we call it now the new website manner right you're doing a video call, you're, you're being able to have enough time because both the doctor and patient are saving time from having to do a lot of the logistics in a clinic. You're able to address their urgent issue but then get to know them as a person. Maybe they have their family there because it's easier for families to join when it's when it's virtual maybe you get a sense of their home environment which like Susan said is critical to understanding who a person is where it's flexible like if look if you decide during that visit that hey there's something missing here, and I actually need to see them in person that you have the ability to convert it to an in person visit whether it's in their home, or in your clinic right. I think that it's really about how we design it and I think that's the sort of going back to this moment we're in Steve is is is is it is a catalytic moment. And it's a catalytic moment where we can make some really bad decisions that will have repercussions for years, you know, because like you said we tend to be reactive we have this reactive moment. So the question is, what are we going to use it to really move care forward and reinvent it, or are we going to have to be more of the same, or actually, are we going to make some aspects of it works, Susan. Well, I think that's the case I mean I think we have a once in a century opportunity to redesign America's healthcare system with, you know, marrying technology and public health and medicine with some new transformational approaches that you know make care more accessible, give more resources to the healthcare providers that focuses on the patient moves care from the hospital to the home and emphasizes the power of prevention to address COVID and many other health care challenges and opportunities that. Susan, we have we have two questions that are right in that same space and I'm going to link them and start with you and move to Shantanu. And this is what kinds of technologies or innovations in care, can we expect to make an impact in the post pandemic era for other health care challenges interesting what can we do that applies to other stuff. That's part one part two is what's the most important lesson we've learned during this pandemic that will revolutionize healthcare long in the future so I'd love you to take a swing at both of those and ask you to do that because I think it builds into that question of what do we need to build that's not there. Well, I think the one thing one lesson is you know as I said earlier that history tends to it doesn't repeat itself but it tends to rhyme that we have to remember the public health lessons of the past and, and marry them with the principles of technology and science, and, and human and social sciences to really address future challenges. And, and I think that you know that that will will move us forward significantly. Tell me your your second question. I think the second question is what is the most important lesson we've learned that can be useful well into the future. And I think some of the technologies that we're talking about are, you know, as Dr. Nundi talked about you know home monitoring. You know it's you can measure your blood pressure you can see, you can do dermatologic checks you can do I checks I mean, all of this can be sent through computers, you can ask for social supports there can be home testing. I think that we're trying to, there will be, you know, blood markers that can be done from home. So I think all of these things will be helpful and I think social support and bringing the health care provider to you is very important because of all the barriers that exist to get to the hospital to get to the clinic. And the lesson, you know that is that we really from infectious diseases that they've killed more people than war and we have to remain vigilant against them for the chronic disease pandemic that many of the lessons of building a resilient public health infrastructure. We have to invest in it today, so that it will work for us tomorrow, not just for the pandemic but for all the other chronic diseases that will affect us now and in the future. Shantanu your thoughts on both of those. I love these questions. You know, what I really think that is sorely missing is we don't have a vision for where healthcare needs to go. Right, the closest thing might be people say well we need Medicare for all or some version of that and that's super important we need everyone in this country to have health insurance affordably and no question about it, but those are health financing questions. What we haven't done is actually say what's our vision for our healthcare should actually work. Right, like two weeks ago on a Saturday at 7pm. My daughter who's seven started having trouble breathing, somebody she's never had happened to her before. And you know like to worry parents even though we're both doctors right we're sitting with her we're doing the vix vapor rub and turning on the steam in the in the shower and trying other over the counter remedies. And at some point we're scared. And we're looking at her daughter and saying, Oh my God, like what do we do. And that's the moment, that's the moment where healthcare happens. Right. That's the moment and yet the entire healthcare system starts when you walk into an ER walk into a clinic or walk into a hospital it doesn't start the moment that you have to really start looking at their daughter and saying, What now. And I think what we need to do is, is really have a very clear vision. And that's what I've tried to outline, you know, is to say care needs to be distributed. It needs to meet people where they are at home in the community online it needs to be digitally enabled we need to use technology and data to actually strengthen relationships the most important relationships in healthcare. And we need to decentralize we need to give way more resources to frontline workers and to patients like my wife and I staring at our daughter to figure out what to do next. Because instead what we had is we started calling up our doctor friends figured out what medication she needed to be on right when I called her clinic they said call 911 and after that it said call your health plan. Right. And then when we figured out what medication to get then at eight o'clock in that on a Saturday where were you going to fill the medication. So we're looking online we're finding a bunch of 24 hour pharmacies we call them guess what it's not the pharmacy that's 24 hour it's the store. Right. And after multiple calls so these are the moments where healthcare happens and we need to have a very clear vision so that all the things that Susan said the remote monitoring and the home testing. All those things yes and AI and all that stuff, but it needs to have a very clear. What is it we're trying to get to and what we've learned as a country I think one of the great things is look at how fast we mobilize the vaccination. Right it's still not as good as it could be and there's lots of mistakes but I mean compared to where we were in January to where we are now it's, it's lightning difference and I think a huge part of it Steve was because we put a marker down we said look, the vision is we're going to get to X million shots by why date, and that mobilized a whole of sector approach to say this is what we have to do so I'd love us to say hey by 2030 we want 30% of hospitalizations to be at home. By 2025 we want 10% of people with diabetes to reverse their diabetes and get off medications completely, but we can do that we can set those markers create real urgency and accountability and then mobilize a whole sector approach, consistent with the vision for where healthcare has to go for people for normal everyday people who are in the rooms with their children figuring out what to do. That's the level of granularity at which we need to define what healthcare should look like. And that's that's great just as we wrap up I want to go to Susan, and, and so you can throw whatever else you want to do in there but I want to get this element there because when I heard oh you're working on another website and I know I respect the website so But, but you're involved with something called beat the virus.org which I think reflects that urgency that Shantanu just talked about, and is cool. And by the way, yes I can, you know it's public record, you know, Susan Blumenthal happens to be married to Senator Ed Markey and I watch his videos. I mean, Ed is really cool on TikTok. And so part of it is, how do we, you know when you talk about getting people where they're at, you know, it's, they're not all going to be watching MSNBC or Fox or CNN, very, very few Americans actually overall watch those. So it's going to these other places finding them in other spots. And I have to tell you while you've been talking I've been clicking through beat the virus.org, which is really quite cool. So can you talk to us a little bit about the importance of these platforms, and also the vibe of them in terms of drawing people in, and we'll have you both comment and there, Susan. Well, thank you. Well, I think it's the pandemic really showed the importance of partnerships. When, when, when it hit, I was working with the MIT Media Lab, and you know, we wanted to do something and so building the website, getting out proven public health messages because there, you know, at the beginning of the pandemic, it was like 1918 all over again, we didn't have vaccines then we all we had were proven public health messages we reached out to the entertainment community. And sure enough, we had 600 million media impressions within a few months, using celebrities and athletes to get our messages out we've now built it out as a resource hub, and using the social media platforms but I think there are so many ways to get information to reach people. I encourage those on the call to, to check out beat the virus.org and to share it with your constituents and friends and family. But you know we need to find other ways to reach people not everyone is going to, you know, get the message the way we do. Really, you know, Louie Pester once said chance favors the prepared mind. I think we, you know, going forward need to remember the lessons from this pandemic. We need to, you know, as I said earlier, marry them with public health and science, and be innovative. Together, public health technology design experts, and, and medical ones to really reshape and reimagine the future for health, because as Ralph Waldo Emerson said, the first wealth is health and we've learned that so well during this pandemic. Last thoughts. Yeah, absolutely. I think maybe I'll end with how we started I think Steve your question about proactive versus reactive. Right, if you look at just our personal lives right a lot of us have reflected on how there's been silver linings for us, right, the family dinners the, you know, learning how to cook slowing down the less travel. And I think at some point, as we start to get back to normal we're going to have to ask ourselves, well, which are those things do we want to sustain, and which are those things that we want to continue to accelerate. And that's really the moment we're in now. I really believe that healthcare at the true front lines has changed more in the past 12 months and it hasn't any 12 months and it's modern history. And that's thanks to a reaction a reaction to a global pandemic. The next phase of this is on us. Right, we have to decide and I say we in the broadest sense possible patients doctors, policymakers, technologists and we have to decide where we want to go with this now. And I think what we need is that shared vision, and what we need to act with urgency because we know, just like the bad habits of not having dinner around the table together we're going to creep back in once we're all flying around and doing different things. Things going to happen on healthy in fact it's already happening. And so we have this very narrow critical window to really move the system forward and so I would just welcome everybody here to roll up their sleeves with us and help us take that next step. Well listen I want to tell our audience that if you go to the right hand chat box should be the, you can click chat and come over there, you have lots of cool links there's a link to where you can purchase. There's a new book through New America's partner solid state books. There's also a terrific I'm not biased because of this, an op ed that the two co wrote in an op ed on the future of healthcare and a post pandemic world that ran in the hill on Friday and the link is over there. There's also a link to beat the virus.org so all of that is available to you. I just want to say a big thanks to Rear Admiral Susan Blumenthal who's the director of the health innovation club at New America, and Dr. Shantanu Nundi, who's got so many tells cheap medical faculty but the only thing we really care about today is he is author of care after COVID. Thank you both for joining us and thank you all for joining New America today. Thank you so much. Thank you. It was really pleasure. Thank you guys.