Month: May 2020

We need to figure out how to make the shift from face-to-face medicine to virtual medicine

Coronavirus conversations

Coronavirus conversations

Dr. Ram Raju, SVP and Community Health Investment Officer at Northwell Health

"We need to figure out how to make the shift from face-to-face medicine to virtual medicine"

paddy Hosted by Paddy Padmanabhan

In this episode, Dr. Ram Raju discusses how the global COVID-19 pandemic has impacted Northwell Health and how in future healthcare delivery systems will change in response to the crisis.

Northwell Health is one of the largest health systems in New York and has been a telemedicine leader for several years. Dr. Raju believes that healthcare systems will need to evolve and change their workflow as more and more people will be seeking care through virtual technologies. Primary care will leverage technology to shift face-to-face medicine to virtual medicine, while specialty care will stay in the hospitals.

Dr. Raju also believes that storing data in the EHRs and EMRs is going to be very different in the future with more data in video clips than text notes.

Dr. Ram Raju, SVP and Community Health Investment Officer at Northwell Health in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “We need to figure out how to make the shift from face-to-face medicine to virtual medicine”

PP: Welcome back to my podcast. This is Paddy and it is my great privilege to introduce my special guest today, Dr. Ram Raju of Northwell Medicine in New York. Dr. Raju, thank you so much for setting aside some time and welcome to the show. New York has been at the center of the COVID-19 pandemic. Can you share a little bit about what the experience has been at Northwell and how it is impacted Northwell and share a little bit about your COVID-19 response efforts?

RR: This is something which none of us ever prepared for, even dreamt about. Northwell, as well as the other healthcare delivery systems in New York City, has really raised up to the challenge and especially the providers and the frontline workers have done a fantastic job of managing the flow of the patients, testing them, treating them, and able to stay with the patients and putting themselves at great risk. The health system has done a remarkable job of trying to save as many people as they could. So, this has been a story of the greatest success. We should be in this country, which really had such a devastating epidemic with a tremendous amount of sacrifice on the part of the people to get this done. Now we see a diminution of the number of patients who are coming to our EDs with the virus syndromes, as well as to the number of people who are in the ICU and the number of people who are on the ventilator. All of them are showing a very, very good downward trend. So, it looks like we are probably behind the apex of the curve, but this also has to do a lot with what the government has done and also the discipline of the New Yorkers in practicing very, very strict social distancing, which has helped us a lot.

PP: Thank you for providing us with that background. I hope for the sake of New Yorkers and for everyone else across the country and the world, that we put this behind us as soon as possible. The healthcare impact and the immediate need of having to identify and treat those that are infected with COVID-19 is one part, there is obviously a significant financial impact to the broader economy as a whole because of the shelter at home and the health systems in particular as a result of the pandemic. I know that the federal government has done its best to help through CARES Act to set aside some money at 100 billion to help hospitals deal with additional costs. Is that making a difference? What is the outlook for hospitals and health systems in financial terms in this coming year?

RR: Healthcare systems in the country have always been on a very thin margin and they do not have much in savings to fall back on. That is true for most of the healthcare delivery systems of the country and New York City is no exception. This has produced a tremendous amount of financial burden on healthcare delivery systems. And the health of the federal government is definitely very much appreciated and very much welcome. And it is also extremely important to keep the healthcare delivery system going in New York City. But the long-term economic issues will be devastating because we have not seen what the long term outlook looks like even after the pandemic is well past us. We will take a long point of time, the economy to gear up to the level it has been there before the pandemic, as well as the confidence of the people able to go back to those restaurants in New York City, those tourist spots, those games, and all those things will take a long time for the New Yorkers and all across the country to get back to the way things were. People have started talking about the new normal after this pandemic. We are going to see a different way of people reacting to it which is unpredictable. I think a large portion of the economic recovery depends on individual behavior. How much confidence they will have in going back to doing things they have done before this without batting an eyelash.

PP: That’s very well-said. Healthcare went overnight to a virtual care model. I imagine like with other health systems across the country, Northwell too accelerated significantly in terms of its journey towards telehealth mode of delivering care. Could you talk a little bit about what some of those big changes in virtualizing your care delivery?

RR: Northwell has been a leader in telemedicine for the last five or six years. And we have used the telemedicine capabilities across our system very effectively in teleradiology, telepsychiatry was a major component of it. And also, our transitional care workers use telemedicine to a great extent to follow up on the patients at high risk and also be used extensively on our readmissions task force and making sure that the people are really taking care of. Having said that, it accelerated tremendously after our experience with the coronavirus. There was a little bit reluctance on the part of the patients adhere to this telemedicine concept. But this pandemic opened eyes and it made it more normal for the patient perspective to be able to get on a telemedicine call and able to chat with the patient. So, in the new normal there will be less reluctance. There is a huge cultural change that has happened. And people will be getting more and more care and consultations through virtual technology to a great extent. So, we need to get it out, get this up. That simply means that most of the healthcare delivery systems in this country have got to really change the workflow issues. There may not be as many patients ever coming to the clinics. And there may be a good number of people probably be seeking care and getting advice through virtual technology. So that simply has got different kinds of processes we need to evolve. We need more people who are having the telemedicine concept. That means we need more hardware, more software, and more situation room kind of things where we are able to guide the patient through the system effortlessly and with minimal delay. But at the same time, on the flip side, the real estate value of having these large clinics, there are large waiting rooms and all those things need to be rethought because there may not be as many people coming through who occupy those waiting rooms in the large clinics which some of the hospitals have built, very recently, to accommodate more flow. We need to really figure out how do we make the shift from face-to-face medicine to a virtual medicine and all the implications with come that. We need to gear up certain areas of our support system to accommodate high demand on the virtual and our doctor’s visit. And we may have to shut down some other areas of the healthcare delivery system which will not be needed as much in the new normal after the coronavirus.

PP: What does that mean for the healthcare sectors? Are you anticipating that there will be more M&A and consolidation? And to a point, inevitably some hospitals just closing. And what does it mean for healthcare consumers in general, especially for vulnerable populations or rural populations?

RR: What will happen is that the places which cannot be done virtually like an operation, or delivering a baby, or some of those things who need to be done in a hospital and are basically a face to face functions. Apart from that the organizations which has a huge reach of telemedicine capacity will probably eat up into the market of the people with the telemedicine were able to attach to the doctors. In other words, if I have an opportunity to attach myself to a hospital A where I was getting my face-to-face care, now I can attach myself with the same ease to another hospital. Hospital B which is like a large teaching hospital. I would prefer to go to hospital B because now the distance does not matter. The geography does not matter anymore. In the past, the geography, the distance mattered where I needed to go to the nearest place. I don’t want to travel like in all 50 miles to go and see a doctor. But now that has changed. So, there will be a tremendous re-shifting of the healthcare delivery system in this country. You will see the hospitals, which are basically doing mostly straightforward medical patients, will probably have a very tough time keeping their doors open. But a hospital might have done, as some specialists like in orthopedic surgery are a neurosurgeon, a spine surgery that cannot be done through telemedicine, though naturally, they will be more in demand. So, we will probably shift from primary care to virtual technology and specialty care will probably sit in the hospitals. And the hospitals need to figure out how can they shed their primary capacity real estate and acquire more real estate on the specialty.

PP: Talking about even the primary care shift in the telemedicine, there are sections of the population, vulnerable, low income, rural, and many others that are still not necessarily placed to receive care for telemedicine modality as a large urban environment that I’m kind of pointing out. There are two extremes here. But do you think that vulnerable populations may not benefit as much from telemedicine as maybe other parts of the population?

RR: You are absolutely correct. That is the point I was making in my last webcast. The problem is this is a group of people or I call them socially vulnerable populations, which has been my main focus for the last 19 years and trying to figure out how can we create health equity, social equity, and social justice for the population so that they can have a level playing field. And that has been a major concern. So there are people who do not have either the literacy level, the knowledge level to able to get this technology and the able to utilize the technology or the inability to access to a computer or a fast internet, which will make those virtual care easier. And then the language issues which come along. I am worried that it will create more health care disparities for this socially vulnerable population. This is the population we call social determinants of health. The population which lives in the food deserts, live in their transportation desert, population who are living in a publicly unsafe. These are people who live in a public housing with a large lead poisoning effect, all those stuffs which they suffer. Now, the fact of the matter, they tell you this healthcare is also shifting to a technology which they are either not capable of utilizing and or they don’t have the technology to get it done will probably be left behind. That has been my major, major concern. But the problem with that is it is apathy. I believe that there will be a further division of the healthcare delivery system in this country from their ability to pay issue will be hospitals which purely cater to the people who are socially disadvantaged, like public hospital systems in the country. And then there are hospitals which are basically catered to the people was got good insurance. So, the two-tiered healthcare delivery system will get further divided. There will be a bigger division and a bigger gulf between their haves and have nots in this country. We will have no further damage; I think the vulnerable population. So I’m very worried about that because the problem with that is the hospitals, which are really trying to stay at the cutting edge of this will probably invest more time and energy on the telemedicine, teleradiology, and telepsychiatry they’re using virtual care will probably think in better investing than opening up the face-to-face encounter, which will probably be widely utilized mostly by socially disadvantaged people. Another name for them is people who are poor, and they can’t afford, and they have no insurance and they are very underinsured people. So, this is a problem which will happen. There will be another shift of the values in this and the question comes in, how do you protect them and that is a bigger question to ask.

PP: There is a lot of food for thought there Dr. Raju. Talking about the technology itself. So, in my podcast, I mostly talk about digital technologies and digital transformation itself for health systems. Now we have obviously seen telehealth kind of take-off and all the visit visitor numbers are going through the roof because of COVID-19. What do you see that health systems across the country are now going to be compelled to accelerate their digital transformation and accelerate their investments in technology to transform the way they deliver care, not just in virtual visits, but a whole range of other things, remote patient monitoring, and AI-led diagnosis and treatment, what is your view on that?

RR: Absolutely, we have learned finally to break the barrier, the cultural barrier of some people believing that they are getting a business done through virtual technologies, somehow inferior to a face-to-face encounter, that is broken. So that means that flood gates are going to open. People are not reluctant anymore to seek care and they’re happy with the care they get through a virtual technology. This is completely going to change the way and most of the hospitals are going to raise towards creating the digital platforms and digital technology in acquiring or contracting that out to take care of the patients. It has really changed the way we do that. And also the way they function, one of the things the hospital systems are seeing like any business system in the country that a good portion of the hospital employees can do not need to be in the hospital or in the corporate headquarters to provide care. They can stay at home and work remotely. And that has created other issues, there will be about one third of the hospitals, a large workforce, maybe working remotely. So that also creates another, both on the employee’s side, how do we manage them when they work remotely, and also from the patient perspective, how can we use digital technology to reach more patients in a much more effective way. All those things are going to make the hospital go in the next few years absolutely a race towards the technology, a race towards the digital platforms all the things that they need to do. Whether it is caregiving or remotely monitoring all those things are going to change your answer. So, there’ll be less of a footprint of the hospital and the footprint will be more by the digital technology, which extends its influence over a larger footprint than they ever imagined in the past.

PP: At the same time, we also must talk about the existing technologies and how we leverage those technologies to integrate them into the future state. So, I’m talking about EHR systems. There’s been a lot of talk about 35 billion, 40 billion in taxpayer money over 10 years. And of course, that is the single biggest digital transformation that has happened in healthcare over the last 10 years, just the digitization of patient records and clearing electronic workflows and so on. Now, some of the deficiencies are the shortcomings of electronic health record systems have been coming up. One of the biggest ones has been interoperability. We saw the final interoperability ruling go through earlier this year. Hopefully, the data flow among and within EHR systems for delivering care and having the access to the data at the point of care is going to get better. What are your thoughts on the final ruling and what improvements in care do you think that is going to result in as a result of the implementation of the final rule?

RR: Even before we talk about the final ruling, we need to think about what is in the EHR or EMR might look like in the future. Yeah, we are moving into the virtual care on telemedicine. The handwritten notes or the typewritten notes are gone. We will be storing the patient’s information and their visits through videos into their EMRs because no one is going to go back and write anything or type anything into it. It’s basically their EMR in the future will be, all of them are basically the video clips of meeting of the patient talking to them. So, the EHR will probably have less typing or less information. And then the video clips, that is what will probably happen over time. That means the interoperability, which has worked so hard to create and connect the various aspects of it will probably take a different turn. And, how do we store the video chats, which are coming from various places, eventually people will need to open the video chat into their smartphone, which has got different technology? People are going to use not just the computer; they want to use smartphone technology to talk to a doctor on their phone like they do FaceTime today. So, the question will be, how will you then we need to have a special way, because those conversations are not necessarily encrypted at the level. We have the documentation and the present time. The final rule is not going to be the final, final rule. It is going to be something very different in the future. So how do we do this, who gets information, who gets to see it? How do you play it back if you need to find that out? The components of the EMR will probably be going to change tremendously. How we store the data in the EMR is going to be very different in the future than it is today. So, we are still trying to make some amendments to strengthening the various rules and trying to get information organized and synchronized across away by all these rulings. Some of them will become moot point eventually because you will not be storing any more documentation in this story, mostly clips.

PP: That is such an interesting perspective. I’ve never heard anyone say that patient medical information in the future is going to be stored more as a video than as text. That is a fundamental paradigm shift in how we look at patient medical information. If that is the case, it needs interoperability and it needs for even being able to access the data in the form it is going to be available in places where it changes dramatically. That is so interesting. What do you see as a path for a return to normalcy and health care operations for the rest of the year?

RR: First of all, there will be new normal. We need to get used to that. There is no real way of doing things. Things are going to change tremendously and it’s going to be different. So, the new normalcy going to be in the future is not going to be in a year. We may open the shops; we may open the hospitals. We may be trying to go back to the way things were which will never be the way things were. Having said that, we are trying to get back to how the life was before it completely closed the economy and the communities and societies in our country. So, as we reopen it, we believe that it will go back to the way it was, but it will not be, it will be completely different. And you will learn as you go along. You will change your habits to great extent. We will probably do things very differently than we’ve done before. So, the economy has got to change with that idea. It’s like, I do not know that we’ll be sitting in a movie theater next to each other and feel comfortable watching the movie or watching the show. I am not sure it will be a stay in our sitting packed up in there in the Yankee Stadium and watch the game. So, all those things are going to change. So, the new normal will be very different. It is going to be, a lot more will be on the virtual level. Maybe there are more people watching those games and more movies on the on the streaming services as opposed to doing that. In fact, starting in a couple of one, one particular group has actually started releasing movies, not in the movie theaters, but streaming directly to the patient. They can actually go and buy the movie ticket and get it streamed into their home. That is a big thing. What will happen to the restaurants? Do we have to wait outside waiting for the restaurants? The normal, as you know, will be very different. This is very difficult to predict because we don’t know what it looks like, how much of tolerance and how much of confidence we will have is something which we do not know what I love. We’ll get better quickly and come back normal on it. Maybe it’ll be a change in life for a long time.

PP: My travel has come down to zero in the last couple of months and I have been a heavy traveler for decades and decades, and I just cannot imagine this. Someone told me this is like a 9/11 moment for healthcare care and more reason why travelers are not going to be the same again. Getting on a plane, sitting next to another anyway, just like you’re talking about Yankee Stadium or a Broadway show, life has got to change as well, among many, many other things. It’s going to be an interesting era, for sure.

RR: Yes, absolutely. That simply means it depends on the fact is how quickly the Broadway or the airlines trying to reorganize themselves and reconfigure the seats? It is going to be something we have to see. Maybe we will have less number of people traveling or more people willing to pay more money or people will be traveling more by car than by plane. So, there is going to be a big shift in transportation would not be in this country really quickly.

PP: Dr. Raju, it’s been such a pleasure speaking with you. Thank you so much for setting aside time and I look forward to staying in touch.

We hope you enjoyed this podcast. Subscribe to our podcast series at  www.thebigunlock.com and write to us at info@thebigunlock.com

Disclaimer: This Q&A has been derived from the podcast transcript and has been edited for readability and clarity.

About our guest

Dr.ram-raju-profile-pic

Ram Raju, MD, combines his executive leadership experience in healthcare with a deep commitment to achieving social equity to improve the health of communities in need. As the Senior Vice President and Community Health Investment Officer, he evaluates the needs of Northwell’s most-vulnerable communities and provides solutions for them by collaborating with community-based organizations. He is responsible for promoting, sustaining, and advancing an environment that supports equity and diversity, and helping the health system eliminate health disparities.

Prior to Northwell, Dr. Raju served as president and CEO of NYC Health + Hospitals from January 2014-November 2016. NYC Health + Hospitals has 42,000 employees, 11 acute-care hospitals, five nursing homes, six diagnostic and treatment centers, more than 70 community-based health centers, a large home care agency and one of the region’s largest providers of government-sponsored health insurance, MetroPlus Health Plan.

Dr. Raju also served as CEO for the Cook County Health and Hospitals System in Chicago, the nation’s third-largest public health system, where he improved cash flow by more than $100 million and changed the system’s financial health during his tenure from 2011-2014. His medical career began at Lutheran Medical Center in Brooklyn and he later served as Chief Operating Officer and Medical Director at NYC Health + Hospitals’ Coney Island Hospital. In 2006, Dr. Raju became the HHC Chief Medical Officer, Corporate Chief Operating Officer and Executive Vice President. Under his leadership, HHC continued to improve quality, patient safety, and health care data transparency.

Dr. Raju served as Vice-Chair of the Greater New York Hospital Association and currently sits on the boards of numerous cities, state, and national health care organizations, including the American Hospital Association, the New York Academy of Medicine and the Asian Health Care Leaders Association. Among his numerous awards and accolades, Dr. Raju was selected to Modern Healthcare’s “100 Most-Influential People in Healthcare.” Modern Healthcare also named him one of the “Top 25 Minority Executives in Healthcare” and one of the “50 Most-Influential Physician Executives in Healthcare.” In 2013, he was named a Business Leader of Color by Chicago United.

Dr. Raju earned a medical diploma and Master of Surgery from Madras Medical College in India. He underwent further training in England, where he was elected as a Fellow of the Royal College of Surgeons. He later received an MBA from the University of Tennessee and CPE from the American College of Physician Executives.

About the host

Paddy is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor&  Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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This pandemic is really showing how efficient and useful a video visit can be and it is here to stay

Coronavirus conversations

Coronavirus conversations

Seth Hain, Senior VP of R&D and Dr. Sam Butler, Leader of Clinical Informatics at Epic

"This pandemic is really showing how efficient and useful a video visit can be and it is here to stay"

paddy Hosted by Paddy Padmanabhan

In this episode, Seth Hain and Dr. Sam Butler discuss how emerging technologies like video visits will become an integral part of healthcare in the future and how the current COVID-19 pandemic is proving its effectiveness. They also discuss how health systems are advancing their virtual care technologies in response to the COVID-19 crisis.

Epic observed 2.5 million video visits in April. Seth states that the changes we are seeing in the industry due to telehealth is not only convenient to patients but also preventing exposure of providers and clinicians on the front line. He further states that the effectiveness of technologies, like contact tracing, will be driven by broader adoption and will need to be augmented to fully account for the whole population.

Sam believes that in future physician’s schedule would be 50% face-to-face and 50% non-face-to-face visits through video, telephone, and an asynchronous electronic visit back and forth. He further states that video visits are here to stay and hopes that these visits will be associated with appropriate reimbursements models.

Seth Hain, Senior VP of R&D and Dr. Sam Butler, Leader of Clinical Informatics at Epic in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “This pandemic is really showing how efficient and useful a video visit can be and it is here to stay”

PP: Welcome back to my podcast, this is Paddy and it is my great privilege and honor to introduce my special guest today, Seth Hain and Sam Butler from Epic. We are seeing some very interesting times in healthcare and technologies currently. Telehealth obviously has gone through the roof in the last couple of months and by now that is old news. We also saw one of the leading telemedicine platform companies announced their results and as expected their numbers are off the charts. Are we going to see telehealth visits pull back to lower numbers in a steady state maybe later in the year or we are seeing kind of a permanent shift of certain types of care to telehealth model by default in the future?

SB: I think that we are going to see video visits as an integral part of healthcare from now on. And it took this pandemic to really show how efficient and useful a video visit can be. In my practice, I did pulmonary and critical care before joining Epic and I can remember many times seeing patients in my office, elderly men in a wheelchair with oxygen. For every visit, this patient had to visit IN every three months, a family member would have to get off work, go get grandpa, put him in a car, get their oxygen set up, get him into the clinic, get him into my exam room, which typically needed some furniture rearrangement to fit the oxygen in the wheelchair. All for me to visit with him for 10 minutes. The physical exam was limited in any emphysema patient. There is not much to hear when you listen to their lungs. And I used to think back then, what a waste for the whole system. The family member usually had to take off work to bring the father in. And many times, I could have done that visit as a video visit. But what stood in the way years ago and up until recently was that it was very difficult to get reimbursement for a video visit. In fact, Medicare had this rule that the patient had to go into another healthcare system and sit in an office and then do video between that office and the doctor or you could not get reimbursed. Now, with this pandemic the emergency rules changed, we are allowed to see patients with video visits and bill standard office visits and E&M codes for those visits. We saw 2.5 million visits in April alone and many customers went, we know one customer that went from, thirty-six hundred visits a year to thirty-six hundred visits a day. Video visits are here to stay.

PP: Sam, so you share your specific experience as a pulmonologist, and some use cases have been, for want of a better word, better candidates for tele-visits than others into the recent past. Are we going to see an expansion of the types of use cases for which telehealth is now going to be considered seriously while they were not before, right?

SB: Yeah, it used to be that it was encouraged for you not to do a new evaluation via video visit. And I think from a specialist standpoint, I would have wanted to see that patient with emphysema at least once to get acquainted with him. But the subsequent visits many of them could have been done through video visits. I think other types of complaints and other types of specialties will lend themselves to video visits, things like dermatology and also urging care where you can use questionnaires before the patient comes in. You can say this patient is a perfect visit for a video visit. They are either possibly contagious and you don’t want them to come in the clinic or it’ll be very difficult for them to get into the clinic because of the nature of their illness. For all those things you could do a video visit first. So, I think that the idea that a video visit can’t be used for the initial visit is also in the past.

SH:In addition to the obvious increases that folks are seeing and familiarity that patients and providers are getting with using telehealth platforms, say through MyChart and the changes in billing. We’re also seeing an increase in the number of home monitoring devices that are available. So this is sort of coming on the back of a series of changes in technology that make it more viable as well for that individual to stay in the comfort of their own home and understand things like their pulse ox as part of a visit. Provide that to their provider. Both provides convenience for the patient and in some cases helping not expose the providers and clinicians and folks on the front line as well. So, there’s a variety of positives that we’re seeing start to emerge on top of this.

SB: Now what about the technology to make this happen? I think as we get more home, in-home technology like oximetry and spirometry and even a stethoscope that could be placed on the patient’s chest and to be then listened to or recorded and listened to by a provider, all those are possible. In fact, I recently attended a conference where the discussion was, how do we get more lung function data directly into the EHR and one of the attendees at this workshop was a patient. And he had undergone a lung transplant a few years ago. Every day he does some spirometry, which is he measures his lung function. He does it in a handheld device. And it immediately goes up through his handheld device right into the EHR. And he did that. He said, let me pause during this introduction and blew into the device. And he said, I just sent it to my transplant specialist. So, they will have a very early warning system if he starts to have a problem with his lung.

PP: All these use cases point to a fascinating future in terms of technology-enabled remote care models. In the immediate present, though, with COVID-19 upon us and we’re kind of somewhere in the middle of this crisis. What are you seeing health systems doing in terms of advancing or modifying their clinical care protocols with the virtual care technology, not just telehealth consoles, but other things digital screening you mentioned a couple of uses for remote monitoring?

SB: Many of our customers have enabled and spread quickly pre-visit questionnaires for patients with COVID. So, if you use MyChart, the patient’s portal and say that you’d like to come in and you have a concern about a fever, cough, or shortness of breath. We can direct the patient to ask to a questionnaire. That questionnaire can be easily changed, as recently the CDC added additional symptoms to the presenting symptoms of COVID so we can ask about changes in taste, etc. Those questionnaires then can be answered prior to the visit that can direct when the patient does arrive. The healthcare providers know does this patient need to go directly to an isolation room. Is it best he even stays in the car and somebody comes out and tests them in the car? All those different steps can be done using questionnaires of the patient takes before they arrive and even, they can be used in a handheld device. Eighty-one percent of patients in the United States have a smartphone. But those that don’t can use their computer with an internet browser or even use family members’ or friends’ as long as they have proxy access to their record. And that is the first step.

SH:I think that the underlying platform that organizations are using with the Epic EHR at their core allows them in the context of something like COVID to deploy these tools quite quickly. For example, Cleveland Clinic kind of went from an idea around how to use MyChart care companion to have it deployed in 10 days. And now they are using that in sharing that content across the community, seeing other sites with 15 organizations, using it in another 70 implementing it. And it’s been that kind of core platform that allows those organizations to innovate in that way and then to spread what they learn to other organizations to help all care for their patients more effectively. I think the other interesting piece here is that these tools both help at the point of care in regards to those patients who haven’t been able to fill out their questionnaires at home and provide asynchronous visits, but they also help with public health where we have deeper information and a better understanding of symptoms across the population, for example.

SB: The first part was questionnaires and the second one was the Care Companion. Care Companion is a tool that we use, typically we thought it’d be great for monitoring patients with diabetes and heart failure at home over a protracted period of time. But it is being used for now with COVID to monitor patients with confirmed or presumed COVID infection, monitoring them while they stay at home and doing early detection of symptoms that would indicate they need to come to the hospital. And Cleveland Clinic developed that from zero to in place in 10 days. And then that have spread that to other customers as well. The actual content of the protocol. So, patients can be monitored at home, given daily tasks to monitor their temperature, their oximetry, their symptoms. They have tests to read and become more educated in as they start to feel better, what should they do to keep their family safe for their friends and as they go back out in the community? So, there are educational tasks and then the questionnaires and data that they’re entering are automatically monitored. And if a problem develops like declining oxygen saturation, even before it becomes abnormal, they can be sent to a case manager who can then contact the patient and do one of those video visits we talked about to check with them at home. So, it’s all working together.

PP: I actually really like the idea of co-developing a new solution for an immediate need or even for future needs as an example of Cleveland Clinic and then making it available to the broader community of your clients. One of the things that have been in the news as a collaborative effort among technology companies and between technology companies and health systems is contact tracing. What are your thoughts on this technology as an effective tool for checking the spread of the virus and is Epic doing something in this regard? Are you working on a contact tracing tool?

SH:I alluded a piece of this a moment ago in regard to MyChart functionality and I think broadly looking at contact tracing and possible technology implementations for supplementing it in the community. The effectiveness is really driven by broad adoption. And I think that in the context of some of the technologies that are being discussed today, there are reasonable considerations that might limit that adoption in certain contexts. Both privacy as an example for some of the technologies that track and understand what individuals have come in contact with others as well as limitations in regard to the use of those technologies in certain communities and certain populations. And because of that, we see this as one piece of the puzzle in understanding and tracking the spread of disease across the community and helping understand who may need to self-isolate, for example. But it needs to be augmented with other capabilities, both technology as well as kind of good old-fashioned folks reaching out to others to make sure that they’re taking care of themselves and their loved ones and isolating where appropriate. So, we certainly see it as part of the puzzle, but it needs to be augmented to fully account for the whole population.

SB: I think we are improving some of the functionality of MyChart to allow that. If the patient gives it permission to have like a home screen that says like, I’ve been recently tested, and I am negative. So that can be and allow patients to enter a negative test from an outside source that didn’t come from the health care system.

PP: I think there’s a lot of questions on the privacy aspects of it, but also the effectiveness of the technology. And as Seth spoke about adoption rate in a country like Singapore, where adoption rates are much higher than as a percentage of the population than elsewhere in the world. Still only in less than a million people have downloaded their contact tracing and in a population of four or five million people. So, it’s still not that high. And so, there are limitations even in a closed, tightly monitored economy like Singapore. Interestingly, the emerging job of the zero is contact tracing. So, it’s going to need a lot of people to actually follow through and track down people who potentially may have been infected, as indicated by one of these contractors.

SH:I think in addition to the contact tracing technology is kind of directly around understanding folks coming in contact with one another using smartphones and other devices to allow folks and enable them to track and understand their symptoms COVID flu-like symptoms, for example, and using that to understand it as population level, how things may be spiking or declining as we’re going through this period of social isolation right now. I think that can provide real value in understanding how and when we can start to open things back up.

PP: That’s a great segment. Hospitals are now turning to AI tools to a risk profile patient and predict deterioration, specifically COVID-19. I know Epic has launched a tool to help with this. Do you want to talk about that a little bit?

SH:We’re seeing pretty broad adoption at this point of using our deterioration index model, which aims to predict twelve hours in advance of, say, a code event or need to transfer to an ICU for a patient on the med surge floors. We are seeing that tool used in the context of patients that have tested positive for COVID-19. As this pandemic started to hit we rapidly released a series of capabilities for healthcare organizations to evaluate and understand that model in the context of COVID-19 positive patients, as well as guidance on workflows to use it in that context and it’s been an interesting set of conversations where they have quickly evaluated how the model performs and deeply understood the impact and value of it in workflow and have been implementing it across. We have over 50 organizations using the model at this point.

PP: We focus a lot of the conversation on this podcast also around digital transformation. Now, COVID-19 has happened, as you look across your customer base and when you look across the landscape in general, are you seeing digital transformation slow down, accelerate or remain pretty much the same in light of everything else that is going on with the COVID-19 response?

SH:One of the keys that we have seen is that by having a solid base of both a kind of critical infrastructure and a foundation across the health system, as well as things like MyChart in patients hands, healthcare organizations have been able to rapidly innovate in a variety of spaces, both on the technology front as well as in regards to their operations. So, we’ve talked about some of the technology pieces such as Cleveland clinics, rapid deployment of MyChart Care Companion, the use of the Deterioration index model for COVID the rapid rollouts of telehealth where organizations have changed their practice. But in addition to that, they’ve also updated their operations and continue to roll out in new ways. And we’ve found that particularly interesting to see how they work.

SB: In fact, one of our customers decided to continue their go live as planned before COVID. They were a pediatric hospital and clinic organization, so they were not as affected by the surge or the preparation for such a surge. So, they decided to go ahead and partly they wanted to be up live and ready to go in the fall if influenza, RSV and COVID comes back. And we supported them virtually. So typically, there is a command center set up that go live with many tens, perhaps hundred on how large it is. People in the command center and physicians like myself go onsite to support physicians. And that was all done virtually remotely this time in a virtual command center that we hosted here at Epic with everybody sitting in separate rooms in a single building. And it was wonderful. We were able to give instant support to physicians who were sitting in front of a computer out in California. And our picture would appear, and we could see their screen and answer questions. In fact, it was better than running around the hospital from one floor to another. So, it is changing. And I think implementation meetings, everything is we are doing so much more over webcasts and video ourselves.

PP: That’s amazing. Coming up to the end of our time here. What does a new normal look like once they’re done with all of this?

SB: I think from a physician’s standpoint, I think the new normal will be as Kaiser gave us a preview of that for a couple of years now, 50 percent of their primary care doctors’ visits have been non-face-to-face and that included a smaller amount of video visits. They did a lot more e-visits. But I think the future physician schedule will be 50 percent face-to-face visits and 50 percent non-face-to-face through video, telephone, and an asynchronous electronic visit back and forth. I think that’s going to be the norm and it’ll be associated with appropriate reimbursement so we can continue to do that.

SH:In addition to that, patient and provider approach to new technologies with telehealth, we will see organizations building out and continuing to enhance their foundational platforms to be able to adopt in the workflow. The implications of large datasets using things like the deterioration index model that I described earlier on a new set of patients to help provide better care and get them home quicker to their loved ones. So, I think it is understanding that in the context of, say, rapid changes in the types of patients and the types of illnesses that folks are addressing. These platforms allow them to help rapidly and quickly care for those patients efficiently for seven sets.

PP: Fantastic talking to you folks. And thank you so much for sharing all of your insights. And I hope to talk to folks again sometime in the near future.

We hope you enjoyed this podcast. Subscribe to our podcast series at www.thebigunlock.com and write to us at info@thebigunlock.com

Disclaimer: This Q&A has been derived from the podcast transcript and has been edited for readability and clarity.

About our guest

Seth Hain, Senior Vice President of R&D at Epic, focuses on ambulatory clinical care and the integration of analytics and machine learning into healthcare. During his 15 years at Epic, Seth has also led the system and performance team, with an emphasis in database performance and architecture. A native of Seward, Nebraska, he received a B.S. in Mathematics from the University of Nebraska and an M.S. in Mathematics from the University of Wisconsin. Seth currently resides in Madison, Wisconsin with his wife and two children.

SamButler-profilepic

With eight years of senior-level experience in multi-specialty medical group management, along with fourteen years of clinical practice experience, Dr. Sam Butler brings a wealth of knowledge to his role as leader of Epic’s Clinical Informatics Team, and helps to guide the direction of Epic’s applications. He is heavily involved in the creation and enhancement of features and development of Epic and works extensively to improve physician wellbeing. Sam has a B.S. in Interdisciplinary Science and received his M.D. from the University of Florida.

About the host

Paddy is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor&  Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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Sign up to get Paddy’s Newsletter that is personally curated by Paddy along with analytical notes on the developments for the week.