"We are in a continuum of change in healthcare, augmented by emerging technologies."

Paddy: Hello again and welcome back to our podcast. It is my great privilege and honor to have as my special guest today Dr. Toby Cosgrove, the former President and Chief Executive Officer of the Cleveland Clinic. Dr. Cosgrove was CEO of the clinic from 2004 to 2017 and currently serves as an Executive Advisor to the clinic. He is also an Executive Advisor to Google Clouds, health care and life sciences team. Dr. Cosgrove welcome to the podcast.

Dr. Cosgrove: Well it’s pleasure to be here thank you very much for inviting me.

Paddy: Let me start with a broad question Dr. Cosgrove. What are the top two to three issues today for American medicine as you see it today and what is the role of Technology in addressing them?

Dr. Cosgrove: Well there’s no question that healthcare is driving increasingly into value and we must get value up from our healthcare and that means keeping costs under control, that also means improving the quality of the care. In parallel with that is accessibility we can’t provide great healthcare unless we have accessible healthcare and I think that technology is going to be a major player in all of these things. We need to use that to begin to efficiently and more effectively deliver this healthcare so I am very hopeful and optimistic about the role of technology for providing great healthcare.

Paddy: The talk everywhere you go is about digital transformation of healthcare and we know that telehealth in particular has made significant strides. Now what is digital transformation mean in your view and what is your assessment of the current state of digital transformation in healthcare what do you think health systems need to be doing.

Dr. Cosgrove: Well clearly you know the more as we move health care from art to science that applies says that we’ve got to put numbers to it and more and more we are relying on the numbers in health care, the numbers are piling up at an enormous rate. Think about for example the human genome which is now becoming part of the clinical care that’s got three billion base pairs in each one of them an enormous amount of data, think about the number of journals that are being put out there 5,300 medical journals putting out over 800,000 articles a year. That’s a tremendous amount of data they look at a mammogram that has as much information as a New York phone book used to have in that. So, we are accumulating a tremendous amount of data it gives us the ability to bring science to health care and it then provides both a problem for us managing it all and an opportunity that the opportunity begins to allow us to learn new things and predict things that we’ve never been able to do before.

Paddy: Right and the volume of medical knowledge is growing exponentially, and we’ll come back to that in a couple minutes. Dr. Cosgrove you are now Advisor to Google and so now you have a view of the healthcare industry from the technology provider side of the equation. Now there are several emerging technologies that seem to have potential you know. We talked about cloud, talked about AI, AR VR you know the Hololens type of technologies, voice enablement, blockchain and so on. My firm has done some research that suggests that technology vendors don’t necessarily think that healthcare is moving fast enough to leverage emerging tech. The same research also suggests that healthcare execs don’t think emerging technology solutions are mature enough yet. What are your thoughts now that you have a view from both sides of the equation?

Dr. Cosgrove: Well I think both are true for example healthcare really moves very slowly and I think it moves very slowly for a number of reasons. Obviously when you have people’s lives involved that tends to have people be cautious about how they adopt new approaches. Similarly, healthcare has not gone out and put a major emphasis on adopting new technologies simply because of the pay and for that is an inhibitor in many cases. So, healthcare has moved very slowly in fact one of the disturbing factors and piece of the data is that if you look at when something is proven to be a beneficial new technology between the time that’s proven in the timeline because standards of care is 13 years so healthcare moves very slowly. Second thing is that technology is not been generally as applicable to healthcare and I think part of the reason is that it’s easy to look at healthcare from the outside and not understanding the problems associated with it for technology companies and so I encourage technology companies to begin to get deeply involved in healthcare so they understand the intricacies of it and the odd things that we have to deal with.

Paddy: Right, now staying on that for a second you mentioned the technology provider ecosystem and they need to collaborate and integrate more closely with healthcare enterprises. If you look at the digital health startup ecosystem it’s been receiving a ton of venture capital money. Last year I read somewhere it was about 8 billion dollars in 2018 for digital health startups. Now we also know that many digital health startups are struggling. At the clinic you have your own innovation group that has incubated successful startups and you yourself contributed to several innovations during your career and you hold several patterns. What is the state of the digital health startup ecosystem today? What advice do you have for startups that are struggling in particular.

Dr. Cosgrove: Well I think I alluded this earlier that I think you need to understand and address a problem which is currently recognized by healthcare institutions and integrate yourself and begin to solve those problems in collaboration. I think the idea that there’s going to be a major disruption in healthcare is difficult to imagine. Healthcare is the biggest industry in the United States right now and to think that any sort of startup is going to disrupt it, is I think a little naïve. I am hopeful that the startups will help solve problems that are currently existing and I think that will be a road to successful implementation.

Paddy: Speaking about the larger tech firms then you know we’ve talked about digital health startups and their approach. Now you have an association with one of the largest tech firms out there which is Google and others in that same category Microsoft, and you know Apple and so on they’re also making significant investments in healthcare. Do you think that they have a better shot at it or they have a better handle on how these things need to be managed in order to accelerate this technology curve for health systems?

Dr. Cosgrove: Well large companies got tremendous opportunities because of the resources that they have. They have tremendous intellectual capabilities, and they have tremendous financial capabilities and when you combine those two the potential for being very helpful in changing the and improving the efficiency of healthcare delivery and the quality of the care I think is enormous and I think properly applied this is going to be a major help and dealing with the issues that I spoke about and driving towards value.

Paddy: Right, I read a research report where recently it was published on a big consulting firms that says that technology adoption, the data shows that, technology adoption in health systems is directly a function of the pace of the shift towards value-based care. In other words, you know those that are moving faster towards value-based cares in to embrace technology a lot more than those that are still mostly in a fee-for-service environment. Do you agree with that and if so what needs to happen to accelerate that shift?

Dr. Cosgrove: Yeah, I do agree with that and I agree with that for two reasons. First of all I think organizations that are moving increasing into value are probably more flexible and more open to innovation and that makes some more innovation. More open to innovation regardless whether it’s moving to value or it’s adapting new technology. The second thing is that I think that people don’t recognize that when you are moving to value you have to seek out those efficiencies and this technology is an opportunity to do that.

Paddy: Well let’s talk about AI in healthcare you know. AI has been all the rage and all the buzz in the last year or two and clearly AI is seen to have tremendous potential to improve healthcare. There’s also a lot of hype around it in today’s context some of the other issues seem to be some of the ethical questions being raised about you know the use of personal data and also the potential for bias in algorithms that can end up being discriminatory in practice and we don’t know that there’s a lot of that happening in healthcare but it has been seen in other sectors. When you look at AI what do you think of big opportunities in healthcare and what do you think are the big issues that are going to be a challenge in accelerating adoption of AI in healthcare?

Dr. Cosgrove: Yeah, well I think we do not yet know the true efficiency of AI in healthcare. But I think we do understand that the ability to take large numbers and find the predictive value and discover previously unrecognized associations is enormous. We have been doing this on a much smaller scale for 30 years and we all the more we look at data the more we understand and the more we begin to be able to address previously unrecognized problems. Now AI I think is an opportunity to begin to do that and you know I’ve seen remarkable examples of that and I’m sure that in time we will see more and more. The real question I think is the question about privacy and who owns the data and that I think is something that we’re going to have to work out over a period of time who has the responsibility for it. I think increasingly citizens recognized that their data is not personal. People willingly now give up their financial data in a number of different ways. Is healthcare going to be looked at in the similar sort of a fashion or is that going to be different and I don’t think we know yet.

Paddy: Right. Now the big tech firms notably Google, Microsoft they’ve made tremendous investments in building these advanced analytical capabilities, AI capabilities. Google for instance has its deep mind division which reportedly has really advanced technology that can be applied in the context of health care. At the same time, you know health systems are heavily invested in electronic health record systems. You know Epics’ owner and so on. How do you see these emerging capabilities from these big tech systems that don’t necessarily have a big footprint yet in healthcare? How do you see them integrating and playing with let’s say you know your systems of record like EHR that are deeply entrenched and are in integral part of the hospital operations today?

Dr. Cosgrove: Well first of all you know I think you’ve made a very good point that the EHR are deeply entrenched and I don’t think that you’re going to be able to replace those particularly the major players the Epics and the Cerner’s of the world because healthcare systems have made a huge investment and those technologies. Now the question is how the tech firms play with these electronic records. I thought it was very interesting that the major tech firms came together and agreed last summer at the White House that they would in fact collaborate and share data between them with the permission of the owners of the data and this frankly begins to bring interoperability which is a major thing that healthcare has been looking for a long time. That we didn’t get when we when the government funded so much of the electronic medical record purchase. So, my hope is that as data is stored in the cloud as probably going to be the most efficient way to do that in multiple clouds. Then that gives us opportunity to have interoperability which would be a tremendous bonus for looking after the U.S. population.

Paddy: Right, now clearly there’s been a lot of focus on the interoperability question over the last few years and the CMS and the ONC they’ve been championing open standards for a while and they’re trying to get all the players in the ecosystem namely the technology firms to open up and share data through a common APIs and whatnot. Now I think we you know it clearly seems like there is progress being made and we are going to see that come to a logical conclusion in terms of more open exchange of data among the technology providers. But the technology aside I had a question about the current state of data exchange among the healthcare participants. Such as for instance between payer and provider what is your assessment of the state of data exchange between participants in the healthcare delivery ecosystem and what needs to change for improving outcomes and for lowering costs of care?

Dr. Cosgrove: Well that’s been one of the issues that we would not have that exchange that’s gone back and forth between providers. But as we move increasingly towards value and both parties, I think are recognizing the importance of sharing that data back and forth and we’re seeing that happen increasingly. It remains to be seen how fast that will happen but if you look at major corporations like Optum for example who’s collected a huge amount of data obviously well attached to United. That gives them an enormous advantage to understand how you move to providing value and healthcare. So I think as pay increasingly moves towards capitation or moves towards value you’re going to have to see that there will be increasing collaboration between those two entities.

Paddy: Do you think in that in that same way do you think these shared services programs, ACOs those are the kinds of vehicles that are likely to facilitate this?

Dr. Cosgrove: Yes, absolutely I think that’s where you expect to see it.

Paddy: Right. Well talking about EHR systems again I read an interesting article in the Harvard Business Review just last week I think which quotes a study that healthcare sector spends an extra billion dollars a day due to the additional documentation that clinicians spend time on and there’s some other data points as well. Since 2009 the number of words in an average patient note has doubled to about 700 words and other developed countries are about a third of that in third of the number of words for an average patient. I mean all of this kind of points to sort of a documentation burden on clinicians and we know that since EHRs came into being we’ve seen a lot of over work on the physicians and incidences of burnout. Where do you see the industry two to three years from now in terms of addressing this challenge?

Dr. Cosgrove: Well, this is a huge problem right now across the United States. The burnout rate is about 50% and one study showed that for every hour doctor spends with a face to face with the clinical problem spends two hours in administrative work and that is one of the major contributors quite frankly to burnout among physicians. There’s a number of things that we hope that are going to begin to address this but to me one of the huge potentials is natural voice recognition and when you can begin to get that to be a part of a physician’s recording of data. I think that we’ll begin to release some of the burden that is currently being placed on physicians and their examination. I would expect that that’s going to happen first not in primary care but probably one of the places it will happen will be in the specialties. Because in primary care you have more things that you have to sort out and less defined pieces of information that you need to record and ask about. So that’s why I would think that it might happen first in the specialties.

Paddy: Right, now, switching back to emerging technologies, digital health and digital transformation. There’s certainly a lot of excitement around the possibilities that these new technologies represent. The other side of the equation also is the costs and so the broad question, is you know, is the payment environment, is the current framework of reimbursements, is that conducive to the adoption of these emerging technologies. Where does it stand today, we know for instance telehealth one of the challenges for adoption rate has been the lack of clarity around what the reimbursement rates are going to be and all that is slowly emerging. But is that a factor and what do you see needs to happen next?

Dr. Cosgrove: Well I think it clearly in the adoption of telehealth it has been a major factor. But do you stop and think about once you get capitation, then telehealth becomes a real impetus there’s a real impetus for telehealth to keep people out of hospital, to keep them out of the emergency room, keep them out of the doctor’s offices and that will be the financial spur that drives the adoption and you know increasingly we’re going to see telehealth I think is going to blossom. Right now, Kaiser for example which is a good example of a capitated health care and delivery system sees only 50% of their visits in person and the rest of it are done virtually in one way or another. So, this is I think this is the future of where you’re going to go and I think as the payment changes. And right now, Medicare and Medicaid have said that they’re going to have 50% of payments related to some sort of risk sharing program by 2020. That means that we’re on our road to that that type of environment and I think you’re going to see a takeoff and these sorts of modalities for distance care.

Paddy: Right, right. Now Kaiser’s example of 50 percent of their e-visits is widely coded. It’s also points to another important factor which is that at a corporate level or an enterprise level there’s gotta be some strategic goals or objective towards moving substantially towards a capitated model, towards virtualization of care and so on. We know that there is a trend of you know care moving out of the hospitals into outpatient facilities and eventually into homes which is where all of the emerging technologies sort of play in a big way. So, what are your thoughts on that trend is that is that a definite accelerating trend and you know where our health systems by and large in that journey?

Dr. Cosgrove: Yeah, I think health systems I think are moving slowly in that direction. We’re seeing more and more outpatient surgeries, things become less and less invasive. We’re seeing shorter and shorter hospital stays. The number of hospital beds in the United States over the last 30 years is dropped from a million to a hundred thousand and I expect that the majority of the communities are still over bedded how and so you’re and you’re going to see the acuity of patients who are in the hospital go up and more and more procedures are being done as an outpatient then. On top of that what we are seeing is less and less acute disease and more and more chronic disease and chronic disease clearly is going to be looked after in the home and then the physician’s office as oppose to in the hospital.

Paddy: All right. Well Dr. Cosgrove over the holidays I had the pleasure of reading your book in the Cleveland Clinic way which I believe was published in 2014, in the book you discuss everything in fact you kind of foresee a lot of the things that we’re seeing today. You discuss everything from the merits of group-based practice, EHR systems, technology innovation and even the art collection at the clinic and its really been healing. So, question for you if you were to write the book today what would be different?

Dr. Cosgrove: Well I think that I would talk increasingly about the technologies that we’ve talked about and the potential for those technologies. Both talking about the digital increasing emphasis on moving to digital. The increasing opportunity that provides for analysis for understanding and the technology that particularly are on telehealth, predictive precision medicine with genomics. I think all these are exciting opportunities. If you stop and think right now what healthcare is going to be like five years from now. It is going to be the care is going to be done in a different location or outpatient, the people looking after you are going to be increasingly technicians and non-physicians or physicians extenders of one type or another, the diseases are going to be different in terms of more chronic disease and less acute disease and the treatments are going to continue to get more sophisticated. So we are in a continuing a continuum of change particularly now augmented by at the rate is augmented by the technologies that are now emerging and I think it’s incredibly exciting opportunity for healthcare.

Paddy: Well I have one final question for you in that way. What is your advice to young people looking at healthcare as a career option now, I have a personal invested interest in the question my daughter is a Psychology major who works with autistic children and you know I’m just curious to know what do you think are the prospects for young people getting into healthcare today and what should they be looking at?

Dr. Cosgrove: Well first of all let me say that a lot of people say well you know I don’t think healthcare it’s a good profession now and why would anybody go into it. And I think health care is a tremendous profession. It is providing the tremendous satisfaction from you being able to look after people and you can always count on it making an honest living and being financially secure. It’s not going to be someplace that you go to become a member of the billionaire’s Society in the United States, but it certainly will provide financial stability. So, I am very optimistic about it you see a lot more and more people being directed to that as you see the applications the medical tool way exceeds the number of slots that there are in medical schools in the United States. So there’s no positive people who of high-quality who want to enter the profession so highly I think it’s a great profession and I think you have to be open to innovation and that to me is a very fertile field for advancement and if you are open to looking at new approaches I think there will be endless opportunities.

Paddy: Thank you so much for that, Dr. Cosgrove it has been such a pleasure speaking with you today and once again thank you so much for being on my podcast.

Dr. Cosgrove: Oh, pleasure have been mine. Thank you for the opportunity.

Paddy: Thank You Dr. Cosgrove, bye for now.

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