Dr. Megan Ranney, Associate Dean, School of Public Health & Alpert Medical School, Brown University
Emergency physician on weekends and public health practitioner during the week, our guest this week sees a future where preventative and reactive health care services are blended into one cohesive system that results in better outcomes for populations. Dr. Megan Ranney, Professor of Emergency Medicine & Associate Dean of Strategy & Innovation, School of Public Health & Alpert Medical School, Brown University, takes a multidisciplinary approach to defining the root causes of medical intervention. In this episode, she explores digital health, treatment integrated with prevention, medical training, the waning workforce and how we can optimistically step into a brighter health care future.
Megan L. Ranney, MD MPH FACEP is an emergency physician, researcher, and national advocate for innovative approaches to public health. She holds the Warren Alpert Endowed Professor of Emergency Medicine at Alpert Medical School of Brown University and is Founding Director of the Brown-Lifespan Center for Digital Health. She is also the Associate Dean of Strategy & Innovation at the School of Public Health at Brown University.
Dr. Ranney’s research focus is on developing, testing, and disseminating digital health interventions to prevent violence and mental illness. She has had continuous external funding from federal and foundation grants for over a decade, with over 130 peer-reviewed publications. She serves multiple national leadership roles, including co-founder and Senior Strategic Advisor for AFFIRM at the Aspen Institute (http://www.affirmresearch.org), a non-profit committed to ending the gun violence epidemic through a non-partisan public health approach, and President of the Board of GetUsPPE.org, a start-up non-profit that delivered donated personal protective equipment to those who needed it most. She is a Fellow of the fifth class of the Aspen Institute’s Health Innovators Fellowship Program and a member of the Aspen Global Leadership Network. She has received numerous awards for technology innovation, public health, and research, including Rhode Island “Woman of the Year” and the American College of Emergency Physicians’ Policy Pioneer Award. She is also a frequent media commentator on outlets ranging from the BBC to CNN to the New York Times.
Dr. Ranney earned her bachelor’s degree in History of Science, graduating summa cum laude, from Harvard University; her medical doctorate, graduating Alpha Omega Alpha, from Columbia University; and her master's in public health from Brown University. She completed her residency in Emergency Medicine and a fellowship in Injury Prevention Research at Brown University. She was previously a Peace Corps Volunteer in Cote d'Ivoire. She lives in Rhode Island with her husband and two children.
Show Notes
Dr. Megan Ranney is an ER physician, and a public health researcher and practitioner focused on determining the root causes of ER visits. [03:06]
Integrating prevention with medical treatment. [05:35]
What will the patient experience look like in 2049? [09:16]
How will we use metrics to measure the success of health care in the future? [10:25]
Health care technology-based tools need to be equity-driven and evidence-based. [12:40]
How do we ensure that future technology has a positive impact? [15:33]
What’s the one innovation in health care that would have the greatest value to society? [19:01]
Will technology fundamentally change the relationship between individuals and the healthcare system? [20:46]
Our health care workforce will be decimated over the next year. [23:34]
How does medical training need to evolve? [26:30]
What will be the future role of the hospital? [28:55]
A future vision of health care that empowers patients, providers and communities. [30:41]
Transcript
Jason Helgerson 0:04
I'm Jason Helgerson, and you're listening to Health2049
Dr. Megan Ranney 0:09
We have been driving a wonderful gas powered car of health and health care, and what health and health care is gonna look like in 2049 is more like a Tesla. So we're going to have the same basic structures, if you drive a Tesla, you've still got a steering wheel and a brake and an engine, but they're going to be constructed in a dramatically different way. So we're gonna think about, we need to create whole body health, that's the car we want to create, the circumstances in which each person can have physical, emotional and mental well being, but we're going to deliver it in ways that are really different and out of the box.
Jason Helgerson 1:59
Public health is often referred to as a discipline that seeks to promote and protect the health of people and communities where they live, learn, work and play. But how far can this approach be stretched? Today's guest, Dr. Megan Rainey is an ER physician, researcher, and advocate for innovative approaches to public health, and is more than willing to stretch the boundaries of her discipline. Her groundbreaking research focuses on developing testing and disseminating digital health interventions to prevent violence and mental illness. She's also the founding director of the Brown Lifespan Center for Digital Health, and Associate Dean of Strategy and Innovation at Brown University. Her sightlines into the expanding world of public health is exactly why I'm excited to have her on the show today to discuss the future of health and health care. I'm Jason Helgerson, and you're listening to Health2049. And it's my pleasure to welcome Megan Ranney to our program. Megan, welcome to the show.
Dr. Megan Ranney 2:58
Thank you. I'm delighted to be here with you.
Jason Helgerson 3:00
Great. Well, can we start off by asking you to tell the audience a bit more about your interesting background?
Dr. Megan Ranney 3:06
Absolutely. So I am first and foremost, an emergency physician, I've been practicing for almost two decades now. And spend almost every weekend working in our level one and level two Trauma Center, taking care of really everybody who walks through our doors. But as you mentioned, I'm also at heart, a public health researcher and practitioner. And I've spent the last two decades not just treating patients in my ER, but also trying to look at the root causes of why they come through my doors. And to solve those, whether it is looking on a structural basis at societal issues that drives people to come to the emergency department rather than to go elsewhere. Or finding better ways to help them link to health care and social services after they walk out the door of the emergency department. Those two parts of my life deeply integrate.
Every time that I work in the emergency department, it brings new ideas and tests my theories about what it is that we need to do. And then my research, I try to make sure that it's immediately applicable to people like me, my nurses, my social workers, my EMTs and the huge expanding circles of colleagues that take care of so many of my patients after they leave the emergency department. We're just a very brief moment in a person's health care experience. And so I try to make sure that all of that work really informs my colleagues care as well. I will say as you mentioned that most of my own research really does focus on those issues of violence and mental health, and how we can use technology to both identify problems before they get bad, and then to treat problems after they already exist. So it's everything that goes the gamut from identifying kids who are at highest risk of cyber bullying and helping them to develop resilience to manage those online threats, to work around social media and misinformation, to work around identifying and helping to prevent firearm injury, both before it happens, and reducing the risk of retaliatory violence after our first injury.
Jason Helgerson 5:16
Fantastic. So I love your multidisciplinary background. And I think it's perfect for our program. And that's why we're so glad to have you. So we always like to start these episodes with that first sort of fundamental question, which is what does health and health care look like in the year 2049.
Dr. Megan Ranney 5:35
So I'm going to present a slightly radical and very optimistic vision, which is that we have been driving a wonderful gas powered car, of health and health care, and what health and health care is going to look like in 2049 is more like a Tesla. So we're gonna have the same basic structures, if you drive a Tesla, you've still got a steering wheel and a brake and an engine, but they're going to be constructed in a dramatically different way. So we're gonna think about, we need to create whole body health, that's the car we want to create, the circumstances in which each person can have physical, emotional and mental well being. But we're going to deliver it in ways that are really different and out of the box, it's going to look like having acute care in the hospital be much more limited.
Although I love my work as an emergency physician, we take care of a lot of folks that get to us because those social, emotional and physical needs were not dealt with earlier. It's going to look like using technology more effectively, to identify folks who are at risk to stay in touch with them, and to link them to services that may not be health care based at all, but rather our social community or structural. And it's going to look like involving a wider spectrum of people in what delivering health and health care looks like. Already, there are a lot of great programs around the country that are using community health workers or peer educators who are working with journalists, to help redefine health problems, who are working with lawyers and private business. And I think that by the time we get to 2049, we're going to see a really different sense of who is involved in that definition of health and provision of health care in a way that allows us to expand the boundaries beyond this traditional hospital or clinic-based system that we're caught in.
The last part that I think is going to be part of that Tesla of health, public health and health care, is that it's not going to be public health versus medicine. COVID-19 has laid bare the degree to which prevention is part of treatment. And the degree to which social and structural factors really helped determine people's risk of disease, of their access to prevention measures, and the risk of severe illness and death. None of those are surprises for those of us that have been working in this field for a long time. But I think that for most of society, this was the first time they saw it in such stark relief. And so my hope, and what I'm working towards for 2049, is that we will move from thinking about prevention as separate from treatment. And rather, we'll find ways again, through those integrated care systems, the use of technology, the partnership with new groups of people will find ways to think about prevention. And treatment is much more of a continuum, rather than being separate entities.
Jason Helgerson 8:38
Super interesting. I love your analogy of the Tesla versus the sort of more traditional car and it sort of gets me thinking about, to a great extent Tesla is a fundamentally different vehicle, but at the same time looks so much like your average car, which gets me thinking about the user experience of health care in your vision, how different will that be to your average person, patient, family in 2049? Will the look and feel, the experience for those individuals be fundamentally different or not that different from what we have today?
Dr. Megan Ranney 9:16
Yeah, that's a great question. I think that families, caregivers and patients will still want to be able to connect with an expert caregiver. There will still be times when they need physical touch, and in-person care whether it's to diagnose or to treat, but who that expert health care practitioner is, how they get in touch with them, again, kind of what the engine or the driver of that connection looks like will be fundamentally different. They will still have the experience of being able to go to folks for guidance, for access to medications, for interpretation of symptoms or test results, but they might find that they go to different types of people. And they will likely find that the various health care practitioners and public health or prevention specialists will be connected in a different way.
Jason Helgerson 10:11
Interesting. So in your future state, how will we measure success? Will it be the same kind of metrics we've used today? Or do you envision a different set of measures for success in the system of 2049?
Dr. Megan Ranney 10:25
To me, there are some basic metrics of success that we will retain, we want to know basic morbidity and mortality. Are there disparities in who's getting sick, who's dying? Do those disparities exist according to certain disease entities, or geographies, or race, ethnicity, gender, sexual orientation, socioeconomic status, and so on. I suspect that by the time we get to 2049, we are also going to have more personalized metrics. Right now, for any of us working in the healthcare system, we know that we have to report a heck of a lot of, quote unquote, quality of care measures that often don't have a lot to do with the actual quality of the care delivered. One of the nice things about the world that we're moving into with this increasing integration of and reliance on technology to stay in touch with patients, to deliver care, to check back in, is that we're going to have more personalized metrics about whether or not they're actually experiencing health. I suspect that by the time we get to 2049, we're going to have patient-centered metrics of what health and well being look like, in addition to our classic hospital or doctor's office based metrics that we currently rely on.
Jason Helgerson 11:43
So you paint a vision, I think, very clearly of a very personalized health care system in which, as opposed to sort of a provider-centric system, that is what I would sort of describe the system of today, to one where the person, the patient, the family is much more at the center, and the system sort of works to meet those individualized needs. And ultimately, success and failure is not just a population measures, but also individual measures. So you also talked about the importance of technology in all of this. So you're very optimistic, clearly about technology, not everyone is as optimistic about technology in terms of its role in health and health care. Is there anything about where you see technology going in the next 30 years that brings any concerns to mind or thoughts about things that we need to be careful about in terms of the application of technology in the future state?
Dr. Megan Ranney 12:40
There are definitely lots of concerns, and I will say again, that this is the most optimistic vision. I think the reality is that technology is there, whether we want it to be or not. We saw the dramatic rise in virtual visits during the COVID-19 pandemic, every teenager that I know has an app on their phone to track their mood and their period and various other health issues. Many of us are relying on virtual care providers for things like acne medications, or for men, erectile dysfunction, the technologization of healthcare is already happening. So I think it's on us to create it in a way that is equity-driven and evidence-based.
That said, there are certainly concerns, a lot of the products that are out there right now don't have a lot of evidence behind them. A lot of the products that are out there right now don't account for equity, and in fact, hurt patients who are already at the margins. They're designed in concierge care or forcing people to pay up front for care. They're designed using tools that are not available to many Americans, much less to folks across the globe. And the last concern I have about many current technology-based tools is that the ethics is sometimes a little bit squishy. There have been studies looking at the apps available on the iPhone store on Google Play, and a large percentage of them that track things on the phone without user permission, share information with third parties without user permission. Those of us in healthcare are strictly bound by HIPAA, those who are outside of those covered entities are not.
And so as we move forward to this technology-based framework or chassis for a new version of health and health care, it's critically important both for those of us in health care currently, and for those who are currently outside, to demand that we have data and evidence to demand that what's being designed is being designed for real problems and real people and doesn't worsen existing disparities, and to make sure that it's being done in a way that's respectful of patient's privacy and autonomy,
Jason Helgerson 14:53
I think you very articulately identified some of the major concerns people have around technology and its role in the future. I overall share your optimism, but I also see the potential concerns, and I see them as exceptionally legitimate. But what's the vehicle for helping to ensure that we get the positive out of these new technologies and avoid the negative? Do you see that as something that the government has to solve? Or do you think there's a market solution here, and that the market will help resolve it or is a combination of both?
Dr. Megan Ranney 15:33
I think it's the latter. I think it's the combination of both. I hate to be one of those people who says well, on the one hand, on the other hand, but it really is a mix of the two. And again, I look to some of our best innovations and solutions during COVID as great examples. When you look at how we stood up testing, and remote sign up for testing, it was collaborations between folks like Deloitte or CVS and state governments. When you look at how we set up great technology-based solutions for vaccines that didn't worsen equity considerations, it was not largely the government and state websites, it was community-based organizations working in collaboration with the state as well as private industry to develop tech solutions that were accessible regardless of race, income, geography, broadband access to help people get signed up for vaccines.
So I think that government has a big role to play and the FDA in particular has been quite out front in terms of trying to set standards. I think existing healthcare providers have a role to play, I'll actually say the UK has done a better job of this than the US. There are some lovely systems within the NHS that really help provide easy access to evidence-based, ethical, and equity-driven digital health tools. But it's also a marketplace-based thing. I think patients and caregivers need to be educated and have a way to assess what's the trustworthiness of a given solution.
The last part that I'll say there, and it relates to that kind of point about patients and caregivers and communities being part of the solution, I think that there are a lot of parallels around the work that we're doing around vaccines, vaccine equity and vaccine misinformation with the world of digital health. There is the shiny object, which is often not fact-based, and may actually be harmful. And then there's the real deal. And one of the things that a lot of us are spending time on right now around vaccines and vaccine misinformation can be translated into other disease entities, other forms of technology-based education, communication, connection with patients, creation of those patient communities, we've seen rise up so much over the last couple of years, I think we can take a lot of these lessons that we're learning about how to do this right, as well as about how it's been done wrong, and apply it as we move through the next 28 years, until your 2049 date.
Jason Helgerson 18:08
Yeah, so one of the things that your holistic vision for the future state and I applaud the the multifaceted, multi modal approach, that there's a systems challenge here and that we need to think systematically, but I want to try to sort of get at is if you had to pick one strategy, one structural change in health and health care that the government or the market or some force could drive, what would be the one thing you change that you think would have the biggest, most positive impact on the health of the public in the United States. What I'm trying to get at is, of the myriad of things you describe, the changes, is there one that if you had to pick you think this would be the one you really want to see happen to really see change because it would have the greatest value to society?
Dr. Megan Ranney 19:01
That's a great question. I mean, and again, coming back to that Tesla analogy, the whole car is redesigned, but if it didn't have the battery that it does, the rest of it wouldn't matter. And I think that for me, the equivalent here is that use of evidence-driven, equitable, technology- based solutions to engage communities, patients and caregivers more effectively in their own health. I think that that's the engine that allows the rest of it to happen. Because if we don't have those tools, then you know, we can play with reform of how we pay for things. We can have great connections with community-based organizations, all the rest of it I think needs to go around that core engine that allows us to rethink the way that we deliver health and health care.
Jason Helgerson 19:51
Interesting. So just to double click on that a little bit. So patient engagement and using technology to more effectively engage different types of patients, different types of communities, I see the tremendous value there. How optimistic are you that technology that not only exists today, but is coming in the not too distant future, how effective do you think that's going to be at really transforming that relationship? Because I agree, I think if we move beyond Dr. Google and move beyond an environment where there's a lot of misinformation available or out there in the world and oftentimes, it's hard for providers, individuals, patients, families to navigate their way through all of that. I'm just wondering how optimistic are you that the technology, the tools, are going to come to be and we're going to really fundamentally change the relationship between individuals and the health and healthcare system.
Dr. Megan Ranney 20:46
So I'm tremendously optimistic that the tools are going to come to be, I'm sure you're in the same situation where every day I see a report or talk to a company that's moved the needle on what's possible with technology. I talked to someone the other day who has a program that has pulled millions of counselor, or therapist patient interactions that were done over text, and is now creating a chatbot that really nicely empathizes with patients, helps move them forward, and serves as the basis for a better stepped care model. That is so critically important today. And I'm just using this as one example.
But this that's so critically important today, given the rise in behavioral health and mental health problems across the country, the lack of workforce, the lack of space, the lack of culturally competent providers, that's just one small example of how the transformation happens. And that's happening hundreds of times across the country every month, and nevermind the world.
There's obviously other stuff that has to happen around it, we need to be able to pay for it, we need to be able to make sure that the people that need it have access, we need to be able to make sure that there's actual data on the other side, so it's not a foregone conclusion. But all the pieces of the puzzle are there, it's just a little bit of letting the market drive the solutions, and then a little bit of government and health care providers creating some guardrails around getting the right solutions in place for the right people. I think the fear is that we're going to get a whole bunch of fancy programs that work for folks with disposable incomes, people who are worried well, or people who are truly sick, but have that ability to access a little more.
What gives me hope is looking at programs like City Block Health, or Oak Street Health, that are already using technology effectively, to connect with patient populations and communities that are traditionally left behind. So to me, it's not a question of are the tools going to be present, but rather, do we know how to use them? And are we doing so effectively?
Jason Helgerson 22:58
Great. So talk a little bit about the workforce of the future and how you see it. We've had guests on, like yourself, who wear an academic hat, in addition to other hats. I'm interested in your thoughts about, are we training physicians, or other health care professionals today, the way they need to be trained in order to be successful and be able to meet the demands and needs of the health care workforce of 2049? What do you think about how we train health care professionals? Is it up to snuff? Does it need to be changed and if so, how?
Dr. Megan Ranney 23:34
So I think there are two parts to this. The first is that I think that our healthcare system or our health care workforce, is going to be decimated over the next year. We've already seen people leaving bedside medicine at an unprecedented rate, both because there's a lot of baby boomers who were ready to retire anyways. And because people are just burnt out by this pandemic. So I think we're going to be facing real shortages in nurses, doctors, EMTs and other groups over the next few years that we've got to get ready to deal with. And I think, again, tech is part of the answer there, in terms of how we're training those who are currently in school, and I think of medical students as part of it.
But again, I do have this Associate Dean role at a school of public health, and I think how we train public health practitioners, as well as of course, nurses, social workers, and so on, does need to radically shift. The way that we have been training folks in medicine hasn't fundamentally changed since the Flexner Report in the early years of the last century. The way that we train our public health practitioners is based off of accreditation from our national bodies, that requires core competencies, but doesn't require the type of interdisciplinary thought and external collaboration that is going to be part of this vision of the healthcare system of 2049. And no one is learning in a structured or systematic way, how and when to innovate and push boundaries, and how to evaluate new technologies, not just new drugs or new diagnostic tools, but these new technologies and implement them in a way that truly improves the health of communities. I think many people in the caregiving professions need to learn a little more about, again, data, and that intersection with community and with other specialties. And then the folks on the public health or prevention side, need to be a little more integrated into the healthcare system. And both need to work together more to make sure that we can double down on the innovation that's needed for the next generation of care.
Jason Helgerson 25:43
Do you think we need to have a fundamental relook at the curriculum, at the way we accredit these universities, these programs, these schools? Do we need to bring together a group of right-minded or enlightened people to come together and think differently? Because I agree with you that we are going to see a big post pandemic drop off in the workforce, but we are going to need human beings in the health and public health sphere in the future. And I guess my biggest worry is that we're not training them as they need to be trained. But I fear that these systems won't reform themselves. So what are you thinking in terms of, how do we actually drive change in the various ways in which we train, develop the workforce of the future?
Dr. Megan Ranney 26:30
Yes. That's a short answer. I think there's a few things, one is that a bunch of schools across the country are doing pilots of new ways of training their providers, again, ranging from physician assistants to physicians themselves, to nurses, to public health practitioners. There's also a lot of great new programs that are training people outside of that initial degree. So whether it's things like an Executive Masters in Healthcare Leadership, which we have here at Brown, online only certificate programs, there's a burgeoning world of places that people can get those extra pieces of education. And I think that those are going to provide the pilot data for us to more effectively reimagine what needs to be part of the health care training experience.
The last thing is that I'm seeing a lot of societies step up to the plate. And I'll actually call out the AMA, in particular with our work around racial equity and structural racism, creating a roadmap for many of us to follow in terms of how we teach and interact with our students, our and our patients in our communities. Each of these pieces will help us inform that bigger project that you talk about, that reenvisioning of how we train folks. I think we could do it today. I worry, though, that it would be so theoretically-based, that we wouldn't be able to get traction. I suspect that as we do face this crisis in the next couple of years, it's going to force us to reevaluate, and by then we'll we'll hopefully have data from some of these pilot programs that individuals, schools and societies are doing.
Jason Helgerson 28:13
Excellent. So one more area that I think you're uniquely positioned to get into, given the fact that you're an ER physician, what do you see hospitals looking like, the user experience, the types of services they provide, who works there? Just interested in your thoughts on the hospital of 2049 and what is that institution, which is the top of the pyramid of American healthcare, and, frankly, the health care systems of many countries, what role, what function, how does it operate in the future state?
Dr. Megan Ranney 28:55
So I think we see the hospitals being used really, for those acute care needs. We are going to have a greater number of hospital at home programs, so those patients that we admit to watch them overnight, we're going to have a greater ability to send people home with remote monitoring and with care providers who can keep an eye on people from afar. I think we're going to have greater access to many of the social services, whether it's around behavioral health care, food insecurity, homelessness, or the need for memory care units in nursing homes, that are filling up beds in many hospitals across the country right now. That's going to be more available, more decentralized and we're going to have better systems for keeping folks out of our large hospital systems.
I think the aging of America is going to force us to create those a little quicker. I also think again, COVID, and the shortages in the workforce are going to move us there. I know that my hospital system as well as those of just about everybody I talk to you right now, was completely bursting at the seams and much of it is acute care needs, but a lot of it also isn't. It's stuff that we could provide quite well at home or an alternative care institutions. And again, that we could use technology to help facilitate.
Jason Helgerson 30:13
Excellent. So we always like to end with a question which asks our guests to take a step back and, and you're very articulate vision for the future of moving away from the gas powered car based healthcare system to the Tesla. And so if we're able to achieve your vision, and the Tesla experience is what we see in 2049, how will that make the world a better place?
Dr. Megan Ranney 30:41
Oh, my goodness. It will make the world a better place by allowing patients and communities to have ownership and a sense of self efficacy around health. I think it's also going to help the health care providers, we are all so exhausted with banging our head against this broken system, and not being able to provide the right care to the right person at the right time. Our patients are lonely and afraid and feel like they're not getting answers. Our doctors and nurses feel like they can't deliver the care they want to give because they're so time crunched and don't have any resources. If we can effectively develop this technology-based engine, it will allow patients and communities and caregivers to feel empowered to take care of themselves. It will allow healthcare providers to do the part that they really want to do and do best. It's going to take a load off of everybody, and will hopefully help enhance community level health as well by keeping people centered in their social structures that are such an important part of full body health.
Jason Helgerson 31:58
Wow. And that inspirational and exciting note, we'll bring this discussion to an end. That was Megan Ranney's vision for health and health care in the year 2049. As always, thank you for listening to Health2049. If you enjoyed what you just heard, please subscribe to us on Apple Music and Spotify and share this podcast with a friend. Thank you and see you next time.
