Month: August 2020

Voice technology will enhance care delivery from within the EHR

Episode #57

Diana Nole, EVP and General Manager, Nuance Healthcare and Yaa Kumah-Crystal, MD, Assistant Professor of Biomedical Informatics, Vanderbilt University Medical Center

"Voice technology will enhance care delivery from within the EHR"

paddy Hosted by Paddy Padmanabhan

Sponsored by

In this episode, Diana Nole and Dr. Yaa Kumah-Crystal discuss the progress, future state, and challenges of voice-enabled technology in healthcare. They also talk about its usability and application in a post-COVID-19 world.

According to Diana, in a post-COVID world, we will see more acceptance of voice-enabled technology not just for clinical documentation but as a virtual assistant to command and control things within the physician workflow ecosystem. The pandemic accelerated the willingness and acceptance to look at things differently, such as telehealth; voice technology will be the next. It will be helpful in offering suggestions and recommendations to enhance care delivery from within the EHR system.

Dr. Kumah-Crystal states that the new era of voice mechanics and how we interact with the voice technology is instrumental in making queries and commands in the EHRs to retrieve information. A new dynamic of patient engagement will emerge from voice as a medium and as a method by which a provider engages with EHR in the presence of patient. Take a listen.

Diana Nole, EVP and General Manager, Nuance Healthcare and Yaa Kumah-Crystal, MD, Assistant Professor of Biomedical Informatics, Vanderbilt University Medical Center in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “Voice technology will enhance care delivery from within the EHR”

PP: Hello again, and welcome back to my podcast. This is Paddy, and it is my great privilege and honor to introduce my special guests today, Diana Nole, EVP and General Manager of Nuance Healthcare. And Diana is familiar to our audience. She is coming back and joining us. She’s been on this podcast before. We’ll talk a little bit about that. And Dr. Yaa Kumah-Crystal, Assistant Professor of Biomedical Informatics at Vanderbilt University in Nashville. Welcome to the show. Let me kick this off. Diana, I think this may be a question for you to start with. I’ve always considered voice to be one of those highly promising, emerging technologies that is going to transform the way we live and work. In healthcare, we have struggled with how technology has taken away some productivity, even though it’s delivered a lot of other benefits. Voice has the ability, and voice enablement to voice recognition is potentially one of those technologies that could ease the burden on physicians. That’s been the thesis for the rapid growth of voice enablement in healthcare. So maybe you could start by sharing with our listeners a brief overview of the progress that we have made as an industry with voice enablement and healthcare. Where is voice finding its application today, especially in a post-COVID-19 scenario?

DN: Well, voice has definitely been on a journey. It’s not new to the industry. As I had mentioned, I’ve known Nuance now for 15 years. I’ve recently joined them on June 1st. But voice, dictation, the aspect of taking the ability of this technology to do clinical documentation has been around for a while. More recently, I think with the capabilities of all of our data processing, etc., we’ve definitely advanced where it’s much easier to get adopted. You don’t have to train the system as much as getting much more accurate. And so, the ability to get broader sets of users to use it has definitely kind of come up. What you see now in the post-COVID world is even more acceptance of things where you can use the voice enablement, not for just clinical documentation, but a bit more with like being a virtual assistant and being able to command and control things within the ecosystem that the physician is working in. For example, the announcement on UpToDate was to be able to search through voice and be able to say, hey, dragon, pull up what’s on UpToDate on this particular topic? And I think in the post-COVID world, just a simplistic thing that we’ll probably hear more from here on the show is just the contactless ability to drive and control commands. And we’re getting actually interested in not just the physician, but medical devices and use of that. And so, we also think that there’s gonna be more people wanting to use voice to kind of use in this post-COVID world.

PP: Yeah, that’s interesting. Contactless experience has kind of become a big buzzword and a theme as people start going back into the clinics and hospital environments. We will unpack that a little bit more. Now, when we had you as a guest on this podcast, you were at that time with Wolters Kluwer leading their healthcare business. And now you’ve recently done a partnership with Wolters Kluwer to help clinicians and researchers using the capability for voice-enabled content search. Can you talk to us a little bit about what that means?

DN: Yeah. So, what you can actually do is, you can say, hey, Dragon, search UpToDate for particular treatment options. And this actually then helps the clinician retrieve information in UpToDate. A big thing with physicians is not having to go between systems, but just having it seamlessly. And, then you can retrieve information in UpToDate, a leader in clinical decision support. You can get medication, dosage, disease stage, drug interactions, all that stuff is readily available in UpToDate. And then, you can also with the dragon engine, be able to do commands in terms of what you want to actually have the EHR do. So hopefully being able to get information more easily accessible, efficiency, productivity, just a better user experience. So that’s what we’ve done with UpToDate. And we think that there may be some other things that we can do together on that, so I’m very excited, although I’ve left. It’s really nice to continue to work together in that partnership.

PP: Yeah, yeah. Sounds really exciting. Dr. Kumah-Crystal, you have been using this new technology at Vanderbilt University. Can you tell us a little bit about how you’ve been using it? Are you using it as patient experience, context? Are you using it for research? Can you tell us a little bit about where you’re using this?

YK: Yes. So, I’ve been a voice enthusiast for a long time. I’ve been using dictation to keep my notes. What I’m so excited about is this new era of voice mechanics and how we can interact with the voice technology outside of just the dictation, which is extremely useful, but also to make queries and commands in the EHR to retrieve information. I just think it’s a really exciting new way to interact with technology, because so often when we need to find out something, we’re forced to drill down through different tabs and scroll through sheets and whatever. It’s hard to fight the technology just to give us the information we need. But just to be able to say a command, to make a request and have the information retrieved for you, just takes away some of the burden and irritation of the technology that has kind of integrated itself in our regular workflow. In medicine, it’s a culture of asking questions and making requests. As an attending, I am usually surrounded by fellows and residents and nurses, and we have our morning rounds and we talk about the patient and someone will ask like, hey, what was her last sodium? Or Hey, put that last journal article for so-and-so. And to be able to use that same method, that same medium to ask information for that electronic health record, makes it a more nuanced part of our care team as well, where you can interact with at the same level you’d interact with rest your colleagues.

PP: Yeah. So, what is the big play here? Is it productivity, is it advanced intelligence? What is the play here?

YK: I would say easing the friction of getting to where you want to get to. The whole point of the EHR is that we input information so that at some point we can get it out more efficiently. Unfortunately, because of limitations with time and money and whatever it takes to make it more functional, it’s not that easy to get information out. It’s always several keystrokes away, several tabs away, several lots of things away. But to be able to make a command verbally and instantiate that thing you want, just relieves some of that frustration you have, or you feel like you’re always having to go through a journey justifying the thing you need. I was trying to explain this to my nine-year-old son. He was like, oh, it’s kind of like being a wizard. You just say a spell and it happens like, well, that’s a very nine-year-old way to think about it. But I think I like that metaphor. You just kind of act on the things and they come into being. And I think that’s this part of the value of being able to articulate the things you need.

PP: Yeah and again usability has become a hot topic in healthcare. And in some of the work that we do, usability as a term is finding its way into all kinds of contexts, usability for patients when they come online to access care. And now we talk about usability for caregivers in order to get to the information they need so they can quickly get to answer those pointers for taking care of their patients’ needs. What about the other side of the table? What about patients? How do they get to see the benefit of a voice recognition technology? Is there something that providers are doing to enable voice recognition when a patient walks into the clinic, for instance? You know, Diana talked about this contactless experience. Is that something that the patient can take advantage of as well? Or is it mostly confined today to the caregiver side of the business?

YK: I was so excited to answer this question. In terms of how the patient benefits, there are different kind of ways and manners which the patient benefits. From the provider facing side of things, if a provider can easily call out orders to say like, oh, place a consult for social work or refill the metformin, and maintain their contact with the patient while just asking for those things to be fulfilled, as if they had a scribe in the room or something like that. That itself just helps the patient and the provider feel more connected like they’re in the same place together. And the pride is not distracted by having to pull away and go to their computer screen to answer these things. Also, I think there should be a study of this, but just the benefit of the patient hearing the provider place these orders or make these requests, for patients have better understanding of what is going on in their clinical encounter to know what things the provider thinks is important, to know what things the provider wants to call out. And maybe that would even make it more engaging to the patient. Make them want to ask more questions as about why would we want to try metformin or why did you ask about this specific thing? I think there’s a new dynamic, an element of patient engagement that will absolutely stem from being able to have voice as a medium and as a method the provider engages with EHR while the patient is there. But on the patient-facing side, there’s actually a lot of great work going into having patient-facing voice assistance so the patients themselves can interact with the EHR. And I think that’s just a wonderful opportunity to have people who might not be as comfortable with technology and navigating computers, just be able to talk to their machines and get the information back out. So, I think that’s really, really exciting and can really decrease barriers for people with disability issues because everybody knows how to talk. So at a very early age on people know how to engage with computers and with media using their words and to be able to fully leverage it, I think can take us just a whole another plane of usability and productivity and engage with it. 

PP: Yeah, that’s that is so well said. The importance of having a natural language interface that not only increases your productivity, but also provides some degree of comfort and ease during the course of the doctor-patient interaction is definitely something that I see a lot of other firms paying attention to as well. Now, you mentioned scribing as one of the core tasks of this voice-enabled interface. Now Diana, I want to ask you this question. There is obviously a huge amount of opportunity headroom lift, if you will, for just being able to use voice to do things like scribing, which can actually release a significant amount of time for physicians, but also improve the doctor-patient interaction so that physicians and their patients can have eye to eye contact, and all of the others that has been talked about a lot. What’s next? Tell us a little bit about what you see as the roadmap for the future. Where do you think we can hope to see, let’s say, advanced analytical tools being used in the context of voice recognition to improve our ability to do more advanced tasks, risk assessments, or just being able to predict things from a person’s voice? I’ve read that you can actually read biomarkers in the tone of the voice. Can you talk a little bit about some of the future state that is emerging from voice?

DN: There’s some interesting things. The last note that you had there made me think of something that we recently talked about from Nuance, and that is actually being able to recognize maybe the age. And I’m not quite sure exactly how I would apply that in healthcare, but I think you’re right on in terms of the things that it will allow us to do. What we’re really excited about is, moving from sort of voice and sort of an interaction with one person and the machine to being in this ambient environment. And that is really where we’re focused on. That brings great interaction between the physician and the patient, because now it’s really in an ambient environment. Your diarizing the conversation between the patient and the doctor. And I think that builds a lot of transparency, but also a lot of clinical and other types of accuracy of what’s being captured. And then if we can get that into a very good structured format. Then, the hospital itself can run a lot of analytics on that. You can continue to do sort of the voice commands. But what I see in the future is also the machine helping to catch things that might be within the EHR, or other items that would offer up suggestions, recommendations either in the visit or post a visit to continue to enhance and make sure that nothing falls through the cracks for the patient. And I think when you think about the ambient environment and then what we talked about with patient interactions and producing this capability for other care providers, such as nurses, et cetera, it will definitely unlock and bring back a little bit of what we’ve talked about in the past of bringing back that trust between the physician, the doctor, and their patient. So, I think the whole ambient environment will unlock yet another capability of being able to do analytics, recommendations, those types of things. And that’s what we’re heavily working on right now.

PP: Yeah, ambient computing has, become another hot topic because of all of the possibilities – to be able to remotely monitor or observe what is going on with a patient and being able to pick up things through voice, and other natural language interfaces, especially now in the COVID context. So, does your technology kind of seamlessly integrate with the EHR systems and other decision support tools? One of the big challenges in healthcare is this. All these technology tools, it’s a challenge to make them all work together in a seamless fashion. It’s getting better, no doubt. But still a lot of unfinished business. Do you want to talk a little bit about that?

DN: Well, with our rich history in healthcare, that’s something we rely heavily on, and we definitely have to have those connections. We had long-standing relationships with the EHRs. We can’t do without them, as you said. So, we do have that interaction with them, the virtual assistant. We work with them on how we actually get that information back out and then get it back in. You may have seen recently we did announce, for example, connections with Cerner on that. So, we’re very excited about that. We cannot make it work without it. And that’s why it’s so important for us to be sort of agnostic. We do the same thing in terms of telehealth platforms. So, we work with various telehealth platforms, so we can provide the opportunity to use it for the doctor when they’re in the office or on telehealth. It eases their not having to use a different tool. And then you really just have to work with all these different systems. And that’s something I think collectively as an industry, we are getting better and better at.

PP: Looking into the future, today, when you look at text-based interfaces – you go on your iPhone and you start typing out a text message – it finishes the sentence for you because it’s been observing what you write or what people like us to write on a normal course of the day. It’s been analyzing billions and billions of these messages. It helps you to complete the sentence. Do you think the voice is going to get there? You know, you start to see something, and the voice-enabled interface is going to complete the sentence for you?

YK: I think it’s going to depend on what your end goal is. I think there might be some folks who would find that really beneficial. And again, going through the concept of accessibility, that might be a feature for some people. For others, I think most people really look forward to technology helping to facilitate and optimize what they’re already doing. And one of the joys of being a doctor that is often kind of pulled away from us is engaging with the patient, having a conversation, learning about their story, and able to give them advice. But because you’re often having to pull away to turn back your computer, to type it, you don’t have the opportunity to do that. So, having something like an ambient scribe that can match all the words you say to create your note for you. So, you don’t have to do that will give you the opportunity to be present in that way and complete your sentences yourself. But yes, it would make sense for some folks, for whatever reason, to have a tool that can produce those numerations for them. And I absolutely love that feature in a phone and email; auto-suggests, and complete sentences for you. I also wonder if it’s saying what it thinks I would have said or it’s suggesting what I should say, and if the results of my email are really just the computer’s mind. Regardless, it sounds good and it’s all spelled correctly. So, I can just hit send and save myself an extra five minutes.

PP: I’m not so good with the auto finish. More often than not, I’m sending the wrong message out and manually correcting you.

YK: That’s an interesting point that you bring up. And with regards to the technology kind of just working and not having to worry about all the setup and integrating all that stuff. One of the biggest limitations in the past about voice technology was that because of the word error rate, you almost spent just as much time having to go back to fix the things that it thought it heard as you were trying to dictate. That was a huge barrier to adoption. But with machine learning techniques, even without training, a novice can pick it up and just get started. And I think that’s one of the big factors in making this a more mainstream thing that anyone can and would adopt, because if all you have to do is talk. And that’s something I had to do anyway. Then what’s the Problem?

PP: You did bring up something that I was going to bring up in the closing minutes of our conversation, which is what are some of the challenges with the technology? Obviously, the error rate is one of them and the error rate could be linked to a lot of different things. Accents, for instance. We live in a very diverse professional environment. Healthcare as much as any other industry is very diverse. Do you see this as technology, therefore, that needs to evolve a little bit more? I do agree with you, you know, from all accounts, it’s come a long, long way in the last few years. Diana, where do you see these multilingual capabilities headed?

DN: Yeah, I definitely think that there are going to be some, you know, what’s the level of accuracy that we can, that really delivers the right results. As was mentioned before. So, I think that will continue to get better. And so if you definitely think about the future, where I talked about, you know, being able to scour things and offer recommendations, I do still think that that’s a vision that can be achieved. But it will take a while because, as you know, we all get started, those recommendations from where we’ve shopped, et cetera, and not all of them are quite accurate. I think the other thing that people have helped me to remind myself is that when you think about this type of interaction and patient and patient interactions, we do have to remember that many of our patients still don’t have access to the technology. So, I do think we also want to continue to keep in mind the evolution that our patients are going through. But I am very, very optimistic. I think the COVID-19 has actually accelerated everyone’s willingness to look at things and do things differently. Telehealth is a great example. Voice will be the next. I’m very optimistic that there will actually be some really wonderful, positive things coming out of a very challenging circumstance.

PP: Fantastic. And I guess on that note, we’re going to have to leave it there. Dr. Kumah-Crystal and Diana, it’s been such a pleasure speaking with you. And I look forward to following all the progress with voice. I got to tell you, I am personally very, very interested in where the technology can take us at a personal and professional level. And I look forward to following all the work. Thank you once again for being on the show.

DN: Thank you.

YK: Thanks for having us.

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 guests

diana-nole-profile-pic-aug2020

Diana Nole joined Nuance in June 2020 as the Executive Vice President and General Manager of Nuance’s Healthcare division, which is focused on improving the overall physician-patient experience through cutting-edge AI technology applications. She is responsible for all business operations, growth and innovation strategy, product development, and partner and customer relationships.

Over the course of her career, Diana has held numerous executive and leadership roles, serving as the CEO of Wolter Kluwers’ Healthcare division and president of Carestream’s Digital Medical Solutions business. She was instrumental in bringing Wolters Kluwer's healthcare product offerings together into a suite of solutions incorporating advanced technologies to drive further innovation. Under Ms. Nole's leadership, Wolters Kluwer formed a centralized applied data science team that accelerated the successful introduction of next-generation AI-based solutions for data interoperability, clinical surveillance, and competency test preparation for nursing education.

Ms. Nole is a board director and Chair of the audit committee for the privately held life sciences company, ClinicalInk, and was recently named the first female Chair of the board of trustees of St. John Fisher College, home to the Wegman's Schools of Pharmacy and Nursing. Diana has dual degrees in Computer Science and Math from the State University of New York at Potsdam and earned her MBA from the University of Rochester’s Simon School.

Yaa Kumah-Crystal, MD, MPH, MS, is an Assistant Professor of Biomedical Informatics and Pediatric Endocrinology at Vanderbilt University Medical Center (VUMC). Dr. Kumah-Crystal’s research focuses on studying communication and documentation in healthcare and developing strategies to improve workflow and patient care delivery. Dr. Kumah-Crystal works in the Innovations Portfolio at Vanderbilt HealthIT on the development of Voice Assistant Technology to enhance the usability of the Electronic Health Record (EHR) through natural language communication. She is the project lead for the Vanderbilt EHR Voice Assistant (VEVA) initiative to incorporate voice user interfaces into the EHR provider workflow.

Within VUMC HealthIT, Dr. Kumah-Crystal functions as a Clinical Director. In this role, she works across clinical systems, to perform internal reviews on and provide advice about EHR change and integration projects, with the goals of optimizing products and processes. Dr. Kumah-Crystal remains clinically active and supervises Pediatric Endocrine Fellows and sees her own clinic patients. Her research and related publications define the use of technology to improve care and communication for providers and patients.

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.

The equilibrium between in-person and video visits will be determined by specialty-specific care

Episode #56

Michael Bouton, MD, Chief Medical Information Officer, New York City Health and Hospitals

"The equilibrium between in-person and video visits will be determined by specialty-specific care"

paddy Hosted by Paddy Padmanabhan

Sponsored by

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In this episode, Dr. Michael Bouton, Chief Medical Information Officer of New York City Health and Hospitals describes the significant changes that NYC H + H had to implement in their organization to deploy and integrate new technologies in response to the pandemic. NYC H + H installed hundreds of vital sign monitors linked to EMRs in the first few weeks of the pandemic and integrated them into the EHR system to enable caregivers with actionable, real-time information to address patient needs.

Dr. Bouton also discusses the challenges and opportunities of telehealth and other virtual care models that are transforming the quality of care delivery and interaction with patients and providers. He states that while no one wants to eliminate in-person visits altogether, video visits can increase low-intensity care quality. He believes the equilibrium between in-person and telehealth/ video visits will be determined by specialty-specific care in a post-pandemic era.

Michael Bouton, MD, Chief Medical Information Officer, New York City Health and Hospitals in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “The equilibrium between in-person and video visits will be determined by specialty-specific care”

PP: Hello again, and welcome back to our podcast. This is Paddy and it is my great privilege and honor to welcome Michael Bouton, Chief Medical Information Officer at the New York City Health + Hospitals, New York City H+H, as it’s called. Michael, thank you for setting aside the time. And welcome to the show.

MB: Thank you very much, Paddy.

PP: Would you tell us a little bit about your organization and your role within the organization?

MB: New York City Health and Hospitals or H + H for short is the nation’s largest public health system. We have 11 acute care facilities, a long-term care facility, a couple of SNFs. We also have over 60 clinics in all five boroughs across the city. And I am the enterprise Chief Medical Information Officer and also a practicing emergency medicine doc at Harlem Hospital, which is one of our hospitals in the system.

PP: Thank you for that background. So, Mike, New York has been one of the hardest hit by the pandemic, and we’ve all seen the numbers and everything. Tell us a little bit about some of the changes that your organization has gone through in responding to the pandemic over the last few months.

MB: The pandemic did a bunch of things, one of which is that it accelerated plans, it accelerated some of our digital transformations. It brought us to a place where I thought we might be two years from now, but we were there in three or four months during the pandemic. A couple of good examples are, in our ICUs and our ED’s, we have vital sign monitors that are linked to Epic, so vital sign monitors can be on patients and it transmits to a central station. The nurse at the central station can monitor the patient and then that information automatically kicks into our electronic medical records. So, it’s a great time saver for the nursing staff and it also allows them to monitor up to 36 patients sitting at a station. And in our EDs and ICUs, we’ve had that since we went live with our new electronic medical records in the past few years. However, on our medical floors, our surgical floors, a lot of other units in our inpatient side of our hospital, we did not have that ability. One thing that became clear very early on, in the pandemic, was that the COVID patients were going to require continuous pulse oximetry. We were sending everybody home that had a pulse ox, 95 percent or greater, which I think is appropriate clinical practice. That means if you were getting admitted to our hospital, basically you are hypoxic, and the patient would sometimes deteriorate quickly. So, they really required continuous pulse oximetry. We did a whole bunch of things, telemetry devices cannot do just the rhythm strip, but they can also do pulse ox. And then we went out and bought hundreds upon hundreds of vital sign machines that could do this continuous pulse oximetry. Our medical floors were transformed in the matter of about six weeks from places where our nursing staff would go bed to bed, taking vitals to not having to do that and that was part of our long term plan. That’s something that I had wanted to do for the past year. But from funding, time, and effort, and where we were going to prioritize that shot up very high on our list. Another example is our telehealth, our ambulatory video visits. That’s one thing that we had started with, in a non-integrated fashion, meaning we would basically send a link to a patient, and they could click on it and come in and it was very sparingly used. That whole process has gotten accelerated. For us, the tide of the pandemic was in April. We were doing almost all of our visits either via telephone or the video. That was the transformation we never fully expected to go almost all of our visits. We didn’t expect in-person part of our ambulatory side to go away entirely and it did. It dropped to almost nothing for a couple months.

PP: I want to spend a minute more on the vital signs, the telemetry, the Pulse ox problem that you had to work quickly. I imagine that if you had to go out and buy hundreds of machines integrate them, reorganize your processes, train everybody, and so on. That must have been a gigantic lift for an organization as big as yours. How do you manage it?

MB: It was a gigantic lift. We developed a dedicated team and prioritized it. What we had been working on previously was integrating some of our procedural areas. So, our GI suites were all fully integrated. We took the teams that were doing that, and we focused them on our medical floor. We took anybody who was able to do this integration work and we made this our enterprise’s number one priority. We went from acute care center to acute care center, outfitting the site CMIO, CMO, CNO, like the site leadership. So, from one of our 11 acute care would tell us which unit they wanted integrated first and we would come in about a day. We would get that whole unit integrated. We would do it off the floor without exposing the IT staff to the COVID patients on the floor. The devices would be brought up. We would stay there and troubleshoot, and move on to the next facility the next day. Now, training the staff was difficult because training in the best of times takes time, and doing so in the middle of a pandemic when everybody is already stressed. Everybody already feels like they have too much work because they did. We had a lot of COVID patients, and it was stressful. So, trying to train people in that environment was hard. The thing that we had going in our favor was that this really was a time saver for the staff. So, people that saw the benefit invested the time upfront. But getting them to pay attention for that first couple of minutes, that was challenging. And frankly, that is why we’re continuing the training at this point. No one knows if New York’s going to get a second wave, but we certainly are preparing as if we are going to. Not every single bed in our hospital is capable of continuous monitoring at this point. But we continue to expand our number of beds that can do this. And really, I think what’s more important than adding those devices is that training these and getting our nursing staff and our PCAs, which are our patient care, associate with them. Getting them able to do this is what we are working on right now. It’s really where the rubber meets the road.

PP: I heard someone say that, 80 percent of these kinds of programs, even if they’re technology programs, is really about the people. 15 percent is about process and the remaining 5 percent is tech. And the tech is the easy part. Everything else that surrounds it and putting it in place and making it work seamlessly, that’s where the lift is. And that’s kind of what’s coming through from your comments as well. Let’s talk about telehealth. In the wake of the pandemic, telehealth was forced upon us. Prior to the pandemic we had all been making progress. Every healthcare institution in the country was adopting telehealth to some degree and some were a little further ahead than the others, but there was some progress. At a broad level in the first few weeks of the pandemic practically every institution that had telehealth capability kind of blew through the previous years’ total numbers within the first couple of weeks in terms of just the total visits that they had to manage, the telehealth platforms. Now that was all very emergency driven because of the pandemic. But three months, four months in what are some of the challenges that we are now having to address, having had to put in and accelerate telehealth adoption. What are some of the challenges that you’ve had to address and can you talk about one or two learnings?

MB: Sure. This is also relevant to what you were saying for the vital sign monitors. This is not my key project, telehealth is not my key project. It’s a clinical transformation. So, this is not just rolling up the technology and say, hey, you can do a video visit with a patient now. It’s all of the little workflow things that you didn’t. A couple of things that I’ve seen be successful with others that we are implementing now, they sound small, but I think they’re really important to the user experience. When I say user, I mean the patient and the provider experience. It’s virtual ruling. I remember when I started working at New York City Health and Hospitals, a decade ago, sometimes I would have to go out to the waiting room to call my next patient. We realized very early on that was entirely inefficient and we took that responsibility away from the doctor so we could work at the top of our license. But when we rolled out the video visits, we basically did the exact same thing. We had the doctor initiating the call with the patient, makes more sense in my opinion. It’s having really anybody else, if you have a medical assistant or registration staff, you can have them initiate the call with the patient. And if they’re having trouble, or if the patients having trouble getting on, it should be the MA that calls the patient, not necessarily the doctor. This isn’t different than if I was the one going up, had to call my patient from the waiting room and they weren’t there having to wait three times and go back a couple of days to go back. It would be a waste of my time. But if you can have somebody else do that and you can have your provider seeing another patient or finishing charting on somebody else, it is just a better use of resources. The thing is, we have those resources because the in-person volume went down. So, we had excess capacity of those ancillary staff. It’s really about leveraging mode. And another ancillary staff is that it’s really critical for New York City Health and Hospitals, those are important to a lot of organizations, is interpreters. How do you get an interpreter on the video visit? It’s something like 30 percent of our patient population is not English speaking primarily. So, that was absolutely needed. So, leveraging our in-house interpreters. It’s not just the video interpreters that we can call online, but there were problems integrating with those and we’re working diligently at that. But about using the resources you already have on site to help you with the technology. And that’s where we found the most success in this medium-term period.

PP: Now, related question. And this question probably is relevant in the context of the vital signs monitors as well. Ultimately, you have to integrate the data that is coming of your backend systems or of the devices that you put in front of patients or caregivers as the case maybe that’s kind of your world, I imagine, in many ways, CMIO. So, help us understand the data integration challenges. We know that there are several and they’ve been around since before the pandemic. What new challenges did it create for you and what new opportunities did it create as you really transformed the way you deliver care and interact with patients? Can you unpack that a little bit?

MB: Sure. The challenges when you’re talking about the data flowing in through the monitors: if the nurse is going to bed to bed and they write down the vital signs, come back over to the system and they type it. There might be a manual input of data, meaning that they might actually just type it in incorrectly. But otherwise that data is pretty accurate. If all they are being asked to do is verify that the information coming from the monitor is correct, they just being human like everybody. They might just say, yep, that looks right. And they’ll know the pulse ox might be reading zero because, 70 something percent, it’s not attached, if the patient got up to go to the bathroom. So, you do have various data entering the system, which is problematic. I got to tell you; I did not see as much of that as I thought. I think our nursing staff, there was a heightened level of awareness for our sick patients and they are the ones that were getting these continuous vital sign monitors. So, while certainly it’s something to watch out for, didn’t turn out to be a major problem for us. The opportunity, which is the other side of this, is that we put in a machine learning algorithm that took a whole host of factors. So, a patient’s age, patient’s diagnosis, their vital signs that were coming directly from these machines, their lab values. It actually was able to predict if the patient was going to deteriorate, meaning get intubated, be transferred to the ICU, or die in the next 24 hours. And using this as we use other early warning system to bring more critical attention to the bedside. And that was a major win for us, our staff liked that. In the face of an increased patient volume, we needed that more than ever.

PP: So, this is a great example from a clinical standpoint. So integrating the data to trying to do in real time, you’re running a machine learning algorithm on it that can provide you with some predictive values that help you target the patients most at risk for deterioration, and intervene in a timely manner and save lives. Great example. What about the telehealth side of it? How did you integrate the data? There is an administrative side of it. For instance, you mentioned that you used to send out a link. People would get on and do a video call. How would you link it back to your billing system as an example? Make sure that you capture encounters and the billing put it appropriately. And then doing it all in a HIPAA compliant way so that privacy and everything is taken care of. You talk a little bit about the access side of it.

MB: I think we’re speaking specifically about video visit here. But a related issue would be the incorporation of digital and digital vital signs, digital information coming from the patient that’s not a video visit. So, I’ll hit on that in a second. But in relation to the video, we had patients log in through their portal, primarily. I mean there are a couple of different ways that we did this. During the pandemic, I know somebody who likes to roll out an enterprise solution, get it adopted widely, and have really a single way of doing business. That wasn’t really a possibility during the pandemic. We had to use a bunch of different forms of technology to meet our various use cases. Speaking specifically about ambulatory scheduled visits, we use our patient portal, a large percentage of our patients had already an app on their phone. And if they didn’t have that app on your phone, we required that to put it on to have a video visit with us. Now, people that weren’t able to do that, we provided another means of coming in. But that was our standard way of doing business. And then from a billing perspective, what we realized, and what is not fully my area of expertise, but we did telephone visits and we did video visits. My understanding is that video visits were reimbursing about three times the rate of telephone. So, there was an economic push to move towards video. I think there is a clinical advantage of a video visit. The question is, how much advantage is that? I clearly want to be able to see my patients, then just eyeballing your patient, it has a lot of value. You get a sense of their respiratory rate. But we have both clinical and financial push to move towards video visits.

PP: What about other structures, your in-patient, virtual care, tele-ICU, and stuff like that. Maybe you could touch on that.

MB: We were a little bit further ahead with that for the pandemic, we had more experience. I think its easier to scale something that you’ve already had worked with, than rolling out something entirely new. And that’s true with every project I’ve ever done. This was really no different. So, yeah, we did a tele-ICU. We made it easier for folks to log into the electronic medical record from home and actually see the views of their patients that would be most beneficial to them and specifically in this case, to the intensivist, and then gave the ability for a video interaction. Now, I think video interactions are very helpful with ICU and we clearly did that. But interestingly, the video component in the ICU, specifically when I talk to my intensivists, it was valuable, but not nearly as valuable as I thought because so much of that data was already in the system. And ICU patients have such rich amount of data in the system, you have your event settings, your vital signs, your lab, your nursing. You have so much available in the system already that you don’t need to look at the event if that data is already in your electronic medical records.

PP: Interesting. So, back to telehealth and I want to touch on one more thing that is remote monitoring. Again, this is part of your world. You are taking care of your patients who are out there with chronic conditions, who are not necessarily coming into the hospital. You’re tracking them through devices and wearables and so on. Can you tell us a little bit about how any of that changed? And where do you see that heading in the wake of the pandemic?

MB: Yes, this is such a rich area to move into. I think there’s a huge amount of benefit here. I think most of your listeners will be enthusiastic for some of these specific projects that we worked on. If you have an implantable defibrillator, and you’re at home, you have an AICD, you don’t necessarily want to bring those patients into your hospital to get that device interrogated. Sure, if you’re sick and you need to come in during the pandemic, we want to take care. But if we could do that remotely and if we could get that information from your device without you having to physically come in, that’s a clear cut win. So, we’ve got a lot of projects like that. Now, the other very clear use cases for this are the tracking of your diabetic patients, tracking your hypertension patients. And to me, I think we never want to get rid of the in-person experience altogether. I think there’s a real value in doctor-patient relationship. Face-to-face interaction between hands on the patient, even if it’s not the most clinically beneficial, it has a therapeutic advantage. We’re not looking to get rid of that. But if I’m seeing one of my diabetic patients four times a year and now all of a sudden, I can look at their glucometer on a weekly basis and see how they’re doing and have machine learning algorithm seeing in the background, notifying me when things start to not look so great, that’s a clear cut win. And we’re there. This is not something that, we need more technology for. We are now at the point where we can do that. It’s about developing those workflows. And then what are you going to add to flag a patient like great. This patient is at high risk. But then what do you do? Is a phone call enough? Do you need to schedule for a diabetic, you need to schedule them with a nutritionist? Can you do look at their labs? And I think you it’s going to need to come in and get more lab work. We’re yet to see a whole lot of really rigorous studies on when X happens. This is the intervention that you should do that is clinically proven. And I think that’s really fertile ground for research.

PP: Yeah. Well the hypothesis here is already being validated through marketplace activity. We just saw the emergence of two big companies in this space, Livongo and Teladoc. One is primarily on the virtual consult space. And the other one is in the remote monitoring space and creating a gigantic entity, which kind of is a validation for the opportunity in this area. At the same time, I want to kind of explore the contrarian view a little bit as well. The recent data seems to indicate that telehealth visits have dropped off a little, maybe because they swung too much to one side in the wake of the pandemic. And to your point earlier, nothing replaces in-person care and for certain kinds of needs. I’d call it as an example, it’s hard to manage a condition entirely, remotely. So, we are seeing some of the swing back. But there are other issues related to access for rural or indigent population that may not have the broadband access, that don’t have devices, smartphones and things where you can jump on into a video console. Where do you think we are headed in terms of an equilibrium? Maybe from the point of view of your world at NYC H + H where do you see the equilibrium and what could be the roadblocks you have to overcome in order to really realize the full potential of telehealth and remote care models?

MB: I think it will be specialty-specific, meaning how much is in-person and how much is remote. If I’m going in to see my orthopedist because my knee hurts, there could be a lot of manipulation of my knee. And I think they are going to really need to feel and look at it. I think you’d be able to maybe lessen that on a video then, not none, but less. If you’re going to be seeing your primary care doctor to manage your hypertension and you’re coming in every four months because you’re having trouble with that. Well some of those visits can be done remotely and it can be done remotely without losing a whole lot. I think that the annual in-person physical is also going to be generational to certain extent. When I have the ability now to do video visits, and I can instead of taking a half a day off of work, I can hop out for 20 minutes on a call and then go right back to work. That’s what I personally would want to do as a patient for the foreseeable future. But if I need to go in and get bloodwork done anyway, well, I’d rather just do the visit in person. I’d like to see my doctor. So, it’s a question of the opportunity cost and what the patient is giving up. For example, if you have to come in any way to your ENT to get a scope done and you have an ENT who is going to be doing a scope on me. No, of course, I’d rather come in and get my blood work done and see my provider, all at the same time. But for those remote visits that are amenable to a remote interaction that don’t require physical contact, I think a lot of those are going to go away.

And when they’re settled out Paddy, I have no idea. If we switched to 90 percent video during the pandemic, let’s just say we were 100 percent in-person before. My guess here is we’re going to see maybe 20-25 percent of our visits on a video basis when the world goes back to normal. But after we get a vaccine and people feel pretty safe going back to their normal life, we’re going to see a tremendous increase in our video visits as compared to our baseline of six months ago. I don’t yet see it being the dominant trend. I think what we will see is more opportunities for low-intensity care interactions, which are – “Hey, what happened with your blood glucose? I saw it hit 400 today. What happened?” I could see that the social worker reaching out, but not replacing the doctors. I think it would increase the quality of care.

PP: I think whatever the next normal, it is going to look like what I kind of agree with you. I think we are going to see the needle shift towards virtual care models for many types of care. But then it’s especially dependent. I would imagine that more of ambulatory care and more chronic care is going to be amenable to virtual care models than procedures and things like that. But even for certain kinds of care, to your point, to see an orthopedist talk for oncology as examples. I want to leave you with one more question, which is, as they say – ‘never waste a crisis’. COVID-19 is definitely a crisis, but it’s also an opportunity. Where do you see the biggest opportunity in your world as a CMIO of New York City H + H, where you see the biggest opportunity arising from this crisis?

MB: So we are pretty large system, implementation of our new electronic medical records spanned a few years and we finished in March. So, we put in our long-term care facility in March, right before the pandemic started. It was great timing. What we used this crisis for was to act as a system, meaning we had system level data that we just didn’t have before. When we compared the capacity to bed capacity at one hospital towards another. We were really comparing apples to apples. This allowed us to transfer patients from the hardest hit hospitals to the less hard-hit hospitals and really have a fair basis in comparison for why we were doing so. This improved patient care. I think the strength is to save lives, because if you got a hospital that was way over capacity, we could get them out somewhere else. And the other receiving hospital had all of their data from our other hospital, which is a huge benefit to our system and eased the transfer process. But what I’m saying about acting as a system, the literature of the COVID pandemic changed at a dizzying pace. So, was hydroxychloroquine good or was it bad? There was a time where people thought it could actually do something positively. And I think that’s changed. But there are things that have been proven very effective. So, like dexamethasone, we have a randomized trial showing that it works. So, we have in our order sets, as soon as those trials came out, we added in dexamethasone.

MB: And, there’s a million different examples just like this. But when we made those changes, we weren’t making those changes at one of our hospitals. We made those changes at every single hospital. The reason it was so easy to do for us is that we only have one order set for this. So it drove us towards an enterprise standard and enterprise way of doing business. When we put into vital sign monitors, we didn’t all eleven of our hospitals weren’t buying their own vital sign monitors. We were buying them for them. So, we already had a clear path to integration. So, on the others, these examples and so many more. But we got to act like a system really came together. We were able to achieve more. I think that would best take way for our organization. That standardization allowed us to do more and deliver a better product to our patients and to our hospitals better.

PP: Fantastic. I think that is a fantastic take away. I’m afraid we have to leave it there, but such a pleasure having you on and look forward to following all your work on NYC H + H and all the very best to you and your team. Thank you for being with us.

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

Michael-Bouton-profile-pic

Michael Bouton, MD, MBA is a practicing emergency medicine attending and the Enterprise Chief Medical Information Office for New York City Health and Hospitals.

Dr. Bouton is focused on the development of health systems that provide access to quality care and that are financially sustainable. He was the first director of a homeless health clinic in Harlem, developed a respite housing program for homeless emergency department patients in Boston. He was also the director of pediatric ED at Harlem Hospital before getting involved in informatics.

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.

COVID-19 has given us an opportunity to reset and create a better healthcare system

Episode #55

Podcast with Sara Vaezy, Chief Digital Strategy and Business Development Officer, Providence Health

"COVID-19 has given us an opportunity to reset and create a better healthcare system"

paddy Hosted by Paddy Padmanabhan

Sponsored by

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In this episode, Sara Vaezy, Chief Digital Strategy and Business Development Officer of Providence Health talks about their recently published series of reports – COVID-19 Digital Insight Series – that describes new digital requirements and opportunities brought by the acceleration of virtual care models due to COVID-19. Sara also speaks about the current state of telehealth adoption level and possible reasons for its drop after the industry witnessed a surge in telehealth visits in wake of the pandemic.  

According to Sara, COVID-19 acted as a catalyst for digital transformation in healthcare. She categorizes the transformation happening in the healthcare industry in two possible ways. One, where the industry needed to control and tackle the challenges created by the pandemic and the industry mobilized its IT, digital, and technology services overnight. Second, is considering the pandemic as an opportunity to evolve the healthcare industry and finding new paradigms and ways of caring for people and business models.

She adds that the healthcare industry needs to design better experiences for increasing adoption of telehealth technology. The industry also needs core IT enablers to make it a success and provide better healthcare experiences to both patients and providers. Take a listen.

Sara Vaezy, Chief Digital Strategy and Business Development Officer, Providence Health in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “COVID-19 has given us an opportunity to reset and create a better healthcare system”


PP: Hello again and welcome back to my podcast. This is Paddy and it is my great privilege and honor to welcome back Sara Vaezy, Chief Digital Strategy & Business Development Officer of Providence Health. Sara is very well known and a thought leader in the space and she has just published a series of highly interesting reports on the current state of the healthcare market, especially from a digital transformation standpoint. Sara, welcome back to the show.

Let’s start from the top! Seattle was ground zero for COVID-19 in the U.S. and one of your hospitals treated the first patient. And you had come on this podcast right about the time in the early days of the pandemic to talk about the response effort. I urge our listeners to go back and listen to that episode. Now, you have published a series of papers called – COVID-19 Digital Insight Series and you have titled the series – Journey Toward to the Next Normal. Tell us how the series came about and how you went about putting this together.

SV: Back in February and early March, when we had the first wave of COVID-19 outbreaks in the regions where we serve our patients in the western United States. We had to mobilize our assets across the organization very quickly. That was the topic of our conversation last time, Paddy. As we continued throughout this process, we realized that not only from a build standpoint, we have a significant product development organization that can build technology to address these needs. Everybody had mobilized across the country. Healthcare IT, digital, and technical services needed to address and tackle the challenges that we were all collectively facing within COVID-19. Healthcare systems’ challenges are on full display now. How we are struggling with the business model for healthcare and the strange incentives that it puts in place and creates for providers and for health systems, for instance, in a fee-for-service environment. All these things came on full display, and we saw an opportunity for us to reset and use what is out there and create a better system. So that was sort of the goal that we had. How do we process all that is happening? What are the key trends? What are the things that will be accelerated because of this unique catalyst of COVID, like telehealth, for instance?? What are the potentially new opportunities? What we’ve realized is it’s mostly going to be about acceleration of new paradigms and new ways of caring for people and business models that actually prioritize health and well-being. This was about taking all the stuff that was happening and trying to think about how does this actually contribute to a reimagined system that works better for our patients and our providers.

PP: You have not only looked at what was happening within the Providence system, but also looked across your peer group health systems. You interviewed several people who are in your peer group. Is that correct?

SV: Yes, so it was not just focused on Providence. We did not even stick with just our peer group. We interviewed over 100 individuals that spanned different segments of the industry. We talked with other providers and with payers. We talked with folks in private equity and venture. We spent quite a bit of time with policy makers and folks who had deep expertise on the regulatory environment. We spoke with clinicians. So, we really took a broad approach to this and interviewed folks from as many segments as we possibly could of the industry to get a holistic view.

PP: I read several of the reports, and it’s outstanding stuff, it was very informative and I learnt a lot of new things about what was really going on in the market and the changes. Your first report of the series starts by calling this – The end of the beginning – is kind of an ominous Churchillian reference from the World War II. This quote goes back to the very early years of World War II. We knew that in hindsight that the war was then extended for a few more years. So, I hope your comment doesn’t imply that we’re going to have another four or five years of COVID-19 upon us. The report goes on to talk about COVID-19 and the response effort. But then interestingly, it talks about the first order and the second order impacts. It’s a really interesting framework. Can you help us unpack the structure of the report? How did you go about setting it up this way?

SV: We made that Churchill reference, as you’ve articulated, of course, in hindsight changed our view of how we look at that statement. I would say that probably the same applies in this situation. When we finally published that initial piece, we thought we were at the end of the response phase or the mobilization phase. I think that depending on which region folks are in, there are some still in that mobilization phase. So, there is a bit of hindsight for us in terms of not being 100 percent accurate. Hopefully, to your point, we don’t have another four to five years of this. Knowing that because the situation is evolving so rapidly that it’s likely that some of what we’ve proposed in this is incorrect. So as your listeners engage with the reports and have thoughts, we would love to hear from them and engage in that conversation around how things are evolving post what we’ve already articulated and perhaps proving us wrong or bringing into light new information that would be informative. So, the way we thought about the report was, when COVID started, it was a catalyst. It wasn’t necessarily the reason why things happened, but it was a catalyst for sort of two paths of activity. The first was all COVID related. How do we rapidly adjust to this very acute situation? That was the mobilization phase, so the acute phase dissipates, but its not going away permanently. So, we must continue to manage and mitigate and monitor the situation. So that’s one stream around mobilization and mitigation. The other stream is, in the interest of responding to a very acute situation, what we are now dealing with is that our business has been fundamentally disrupted within providers. Most of the providers had to shut down facilities, brick and mortar facilities, at least for some time because of the unknowns and the risk of exposure. It disrupted our business fundamentally. And then we had to travel down the path of recovering from that. So, it’s not COVID specifically. It was catalyzed by COVID but any other kind of major catalytic event that would have caused us to shut down our clinics would have had a similar sort of consequence. That actually makes way for this sort of next possibility where we have an opportunity to take a good, hard look at how to evolve from where we are. We have to immediately get back to recovery and understand how we can, in the near term, get back to business. But then in the long term, this fee-for-service model, for instance, isn’t necessarily working for us. How can we evolve pass that and use this as an opportunity to do so? It’s really not a COVID-related path of work. It’s more about continuing to serve while evolving. It’s that sort of classic refrain of changing the wheels on a moving car or something like that. And then both kinds of paths result in a bunch of different ultimate consequences. Mental health, behavioral health, for instance is a hugely impacted area. The second-order impacts and outcomes in this report were not intended to be lower priority, but just that they are impacted by these two streams and everything that’s happened across the industry. So that’s how we thought about it in terms of the most fundamental drivers of change. And then other impacts and outcomes that were a result of that.

PP: So, there is an underlying theme of an industry in transition, transformation and everything that you have taken for granted about the fundamentals of the business now up for discussion. The report talks about business model transformation, new norm for patient safety, such as contactless experiences that you were alluding to in the context of COVID-19, and about industry consolidation and what is common. Obviously, financial distress is the reality for many health systems. Then you’ve got the whole supply chain and you’ve got a lot of other things going on. The underlying theme that permeates through all the reports is that of an industry in transition, and how do we get business back to some level of immediate normalcy. But really, It is about how do we prepare for what is inevitably going to be a very different normal, which is what you’re referring to as the next normal. Can you share a couple of big insights that came out of this work that you do?

SV: I’ll give you one that’s very relevant in the context of a lot of change happening, and that’s around telehealth. So, we’ve been talking as an industry about telehealth for twenty-five years, possibly more. But the industry and we haven’t really paid for it. We haven’t had the underlying enablers to make it a success. For instance, we have not had the legislative or regulatory framework underneath to ensure that telehealth was viable from licensure, from a reimbursement standpoint. There are just a lot of the underlying enablers that haven’t been there. Another aspect of it is that we haven’t had a lot of adoption. Most folks had not experienced telehealth as patients and our providers weren’t really using it. Providence itself did not have telehealth as a common modality available to our physician enterprise to serve our patients in our ambulatory network prior to COVID. And what we saw was that now millions and millions of individuals have experienced it for the first time. One insight that we got was that folks are online now, which means that they are more susceptible to not being our patients anymore. There has been this general trend toward patients not being quite loyal to one system or one provider. And with the sort of proliferation of all of these potential telehealth solutions out there, coupled with the fact that folks are now actually utilizing them. They are much more open to being grabbed by a really great experience that’s provided by the 98point6 or an Amazon care. This whole opening it up is like our biggest strength and our biggest weakness at the same time. We now can do telehealth at scale. And unfortunately, if we don’t move quickly enough, it could work to our detriment. So that’s one piece of it. In addition to that, the notion of scale, we built a system that was able to scale, but a lot of the providers really struggled with scale. What we learned was that the industry, from a telehealth standpoint, had been very feature oriented. Because of which the investments did not happen across the board to scale up these technologies. And scale became the most important thing in delivering high-quality telehealth experience that didn’t require hours of waiting. As a result of that there was a lot of the big providers of technology came into telehealth as providers of telehealth, for instance Zoom became a very prominent player as it relates to telehealth. Microsoft increasingly looks at these kinds of things. We think that over time, the actual video conferencing will likely be largely commodities. It’s going to be more about the value-added services and things that you can layer on top of that experience to make it really worthwhile for the consumer.

PP: I actually just published an article in CIO magazine where I explore telehealth in detail. It focuses on the limits of telehealth because ultimately, as administrator Seema Verma said on one of her blogs recently, telehealth is not going to replace the gold standard in-person care in totality. There are several aspects of healthcare that are going to turn towards a virtual care model. But there are limits to that. Those limits are determined by what types of care you are talking about, what kind of populations you’re talking about, and a variety of other things. I have also seen data that suggest that even though telehealth visits, virtual consults in particular and real-time video consults and video visits, dramatically went up in the wake of the pandemic, those volumes have dropped off a little in the last month or so. And there are several reasons for that. There are also obviously the uncertainties around the waivers that are going to stay in place and whether the reimbursements are going to continue and so on. Do you think we are still a long way away from reaching some kind of a natural limit for telehealth penetration in healthcare, or do you think that we’ve kind of tapped?

SV: From a Providence standpoint, we have seen a similar trend where there was a peak and then decline. And now we’ve stabilized. What we are seeing is a result of a couple different things. One is that the experiences for telehealth still aren’t great. As practices started to fill back up and could open with physical visits, it’s difficult to maintain and sustain the peak progress and momentum when the experience is challenged from a telehealth standpoint. It is incumbent upon us to make that experience better, to drive adoption. This is not about all telehealth. I think there is always going to be a mix. And where we have a long way to go is to identify the mix and the kinds of use cases, that work for telehealth because we are still sort of new to this. As an industry, we still don’t know exactly what are the great use cases that we have demonstrated value in. But we have some indications and the more that we can kind of hone the experience and get more data around those use cases, for instance, certain types of chronic disease management can be done really well remotely. Certain maternity care can be done well remotely. Now that we have some folks that have adopted the technology and have experience with it. I think we can start to gather data around how to make those experiences more efficacious and more value added for customers. That’s where we have the biggest runway or ramp up that we still need to engage in. The technology and the experience still need to improve as well. But how we utilize it for which use cases that are most appropriate, is the biggest kind of body of work that we still need to do.

PP: I think that is great insight because there’s so much that is broken or suboptimal in the telehealth experience today that even by just streamlining it can make it a little bit more seamless. Can you tell us what do you plan to do with this body of research ? Firstly, of course, you’ve done yeoman service in sharing with us, which I think is fantastic. What do you plan to do with the reports themselves or the insights that you gained from them?

SV: These are not one and done kinds of things. What we were hoping to do is get the industry kind of talking and start identifying opportunities either for individual systems or individual sectors, also opportunities for partnerships and just collaboration around common themes. That was the big objective, to get the conversation going and make room for collaboration around specific areas. Paddy, you had talked about public-private partnerships that have emerged as a result of this on LinkedIn. I absolutely think that is very interesting and important area where we could accelerate those private public partnerships and make them effective. The second is we are going to use this as a basis for our own strategy. And we are taking a long, hard look at our digital strategy and identifying where we need to pivot, where we need to sort of double down, for instance, as it relates to business model evolution. How can we really support the movement of our organization, to managing risk with specific populations like those folks who are on Medicare advantage? And a unique, interesting wrinkle is that they are older patients. So how can you really make digital work for them? So, we are going to use it in that way. And then finally, we were not intending these to be just one report. We are going to continue to monitor all these trends and update them. And when we are wrong, we are going to write about it. And when there’s new information, we’re going to synthesize it and continue to drive the conversation so that as an industry our learning can accelerate, and we can work to solve these really big problems more efficiently.

PP: Fantastic. That is so well summarized once again for our listeners. For those who could not catch it earlier on in the conversation, the series of papers is titled – COVID-19 Digital Insight Series and it can be pulled off the Providence Health web site.

SV: Yes, you can go to our Providence Digital Innovation Group, Resource Center, which is providence-digitalinsights.org and you can download them all there.

PP: If there’s anyone out there who wants to really understand, get a finger on the pulse of what is going on in digital transformation, especially in this post-COVID-19 era. There’s no better place to start. Sara, thank you so much for coming back on the show again. 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

saraveazy-profile-pic

Sara is the Chief Digital Strategy and Business Development Officer at Providence. She leads the development of the digital strategy and roadmap, digital partnerships with health systems and technology companies, commercialization and digital business development, technology evaluation and pilots, and thought leadership at PSJH.

Prior to PSJH, she worked for The Chartis Group, a healthcare management consulting firm, where she advised clients on enterprise strategic planning, payer-provider partnerships, and the development of population health companies.

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.

Data if done right, has the power to galvanize communities, inform leaders, and empower people.

Episode #54

Podcast with Steve Miff, PhD, President and CEO of Parkland Center for Clinical Innovation

"Data if done right, has the power to galvanize communities, inform leaders, and empower people."

paddy Hosted by Paddy Padmanabhan

Sponsored by

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In this episode, Dr. Steve Miff, President and CEO of Parkland Center for Clinical Innovation (PCCI) discusses how they build connected communities of care with a focus on cutting edge uses of data science, social determinants of health, and clinical expertise across clinical and healthcare community settings. Steve also speaks about his recent book – Building Connected Communities of Care – based on the experience at PCCI.

At PCCI, the belief is that data if done right has the power to galvanize the communities, inform leaders, and empower people. According to Steve, healthcare is a complex, multi-year journey and having a connected community of care during a pandemic, such as COVID, is essential. To control the pandemic, we need better targeting of COVID hotspots, effective and efficient communication between healthcare providers and community-based organizations, and connected services through referral directories.

Steve stresses that while technology is a critical enabler for connected communities of care, there is a need to invest in robust backend data management infrastructure. Take a listen.

Steve Miff, PhD, President and CEO of Parkland Center for Clinical Innovation in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “Data if done right, has the power to galvanize communities, inform leaders, and empower people.”


PP: Hello again, everyone and welcome back to my podcast. This is Paddy and it is my great privilege and honor to welcome back, Steve Miff, President and CEO of the Parkland Center for Clinical Innovation or PCCI, as it is called. Steve, thank you so much for setting aside the time and welcome back to the show. For the benefit of our listeners can you tell us who PCCI is?

SM: I have a huge passion for innovation and to use next-generation analytics and technology to help serve the most vulnerable and those underserved residents across our communities. PCCI has been the perfect place to make this a reality since it is a mission-driven organization with some interesting expertise in what I consider to be very practical application of both advanced data science and social determinants of health. At PCCI our focus is to try to innovate. We are called pioneers in new ways to health. We started the department of health and hospital system and spun out as an independent nonprofit organization in 2012 to not only serve the needs of Parkland but to also pursue additional transformative initiatives that could have a broader impact. At PCCI, we believe data if done right, has the power to galvanize communities, inform leaders, and empower people. We also believe that clinical data only paints a partial picture of an individual and his or her specific needs. Our business model focuses on cutting edge uses of data science, social determinants of health, and clinical expertise across both clinical and community settings.

PP: We covered some of your work in our previous podcast. Since then, you have written a book along with one of your colleagues. The name of the book is – Building Connected Communities of Care. Would you care to tell us what is a connected community of care?

SM: A connected community of care, I consider to be a local ecosystem that is comprised of health systems, payers, community-based organizations, philanthropic organizations, and municipality officials. They are all connected by digital technology and centered around the need of an individual to address his or her social determinants of health. I consider the aim of a connected community of care is to improve the health, the safety, as well as the well-being of the community’s most vulnerable residents and do this in a coordinated, cost-effective, and ultimately sustainable manner.

PP: I was fortunate to obtain a copy of your book and I read through it. It is very interesting and is a great playbook for several healthcare executives in different roles. In your book you explain in detail how to build this community of care. This ecosystem that you refer to of different participants in an individual’s care, especially those who are underserved and are vulnerable populations. This is obviously particularly relevant in the current context of the pandemic. You’re based in Dallas, Texas, and it has seen a surge. But how have the core themes in your book helped in responding to the pandemic? I know the book came out a little bit before the pandemic but felt like a lot of those themes were still probably very applicable in the context of the pandemic. Can you share a little bit of that?

SM: I think we’ve been fortunate that we’ve been on this journey in Dallas for the last six plus years. We realized that having a connected community of care during a pandemic is more important than ever. I think there are three key themes that we’ve been leveraging here locally, as we’ve been trying to connect individuals to better manage the pandemic.

One is targeting. The first thing that we’ve done is to be able to bring social determinants of health data that we’ve had through the connected communities of care with the clinical data and other demographic information and mobility information, and build a corporate vulnerability index. That has been instrumental to give us a very direct and tangible way, to understand where individuals across the community are. They are most vulnerable for not only contracting the disease but also displaying symptoms that require more advanced interventions. So, being able to use that to work with community-based organizations, local government leaders, and several large health systems across the Dallas metroplex to quickly assemble not only the data, but use that to identify and hotspot neighborhood specific locations where the virus is having a disproportionate impact on the residents. To be able to really inform where testing should be done, both physical locations as well as mobile testing and do it in a way that not only meets those needs, but is also very accessible by those that might lack transportation or have difficulty getting to the more traditional points of access. I think that is the first component, the targeting piece.

Number two, is the communication and the value of the connected communities of care communication network to link the healthcare providers and CBOs that cannot be underestimated as it represents a highly effective and efficient mechanism to disseminate information, particularly information that requires both clinical information and a specific element about at-risk population. And we’ve seen first-hand that communication delivered to community residents through familiar entities, whether it’s a food pantry at a homeless shelter or a place of worship, are much more effective than community wide public information campaigns, broadcast, radio or television. They all play a role, but similar to targeting and understanding where resources are needed, targeted messaging aims at specific community residents. In this case, they have been tested positive for COVID-19 or are living in close proximity to other individuals previously diagnosed, much more effective when their communication is done via those known entities in the community. Having already an established relationship via connected community has proven to be very beneficial.

And the third one, is truly connecting services. One of the first things that we’ve always considered to be really important as part of a connected community that technology piece is to have that up to date referral directory of who’s offering services, where and what type of services, who’s eligible to receive those services. As the pandemic started, we realized that those referral directories need to be updated on a daily basis for them to have the right information, because not only the supply of food or other services was becoming challenging, but also the volunteers that the community based organizations were previously heavily relying on. So, the hours and the availability of resources changed. Having an establish connected community and ecosystem to be able to update those referral directories real time became a very important component of managing this on an ongoing basis.

PP: It sounds to me like for all these years, you have basically been preparing for the pandemic in many ways and you were ready when the pandemic hit. You had the information on your communities, where to reach them, who they are. You had the partnerships with the community-based organizations who could reach out to them. And you have the technology infrastructure that could quickly identify at-risk individuals and populations. Now, were you able to enhance the value of this platform or this service, this community that you’ve built by additional partnerships like maybe public health agencies for maybe launching contact tracing as an example? Were you able to turn on those kinds of things as a consequence of the pandemic? Did you have to make any changes to the platform?

SM: Fortunately, we built a platform that is robust enough to be able to manage these very specific, not only personal information but health information. I think it’s a very critical component because we’re able to quickly create data sharing partnerships with the local health department, and that something was an important piece before, but became a critical component during the pandemic. The ability to integrate and merge PHI data with other factors is something that was very important. I think about the technology aspect itself, there are several things that are important.

One, is the ability to integrate and bring healthcare data with other social determinants of health data that requires a level of security that needs to be HIPAA compliant, multifactor security, etc. It requires how you deploy it rapidly and for it to be cloud based, accessible anywhere, we get an internet. That is something really important and also minimize the onboarding process. And that’s something that our partners at PIECES Technologies who are managing this on an ongoing basis. Also deployed a web-based opportunity for community-based organizations to be able to do the right licensing, download this quickly and become part of the connected ecosystem. Those are just a couple of the key elements that have proven to be very important as the epidemic has played out.

PP: In your book, you basically lay out the different phases of setting up a connected community of care as a six-step process. And it includes several things: a legal framework, governance, and so on. Obviously, one of the tracks is the technology track, which is something that PCCI is heavily investing in. I read the chapter, basically the technology track, there are two components to it, data component and the underlying infrastructure component to it. So, in the data and the analytics, you spend a long-time kind of building up the platform. Did you develop any new algorithms or capabilities specifically in response to the pandemic?

SM: A couple of points, one, our patent application for our SDOH case management technology has been approved. And I believe this is the first patent for this type of a system in the space. It’s kind of nice that they came together right when we released the book. I think that is another important development in this journey, as you mentioned, that we started a while back. The key things that have been relevant during COVID-19 are not only the front-end technology itself but its integration with electronic medical systems such as Epic. The technology now is on the app orchard. So that level of integration is important on how you connect to the providers?

I think that the second one, I mentioned briefly was the ability to and download this for quick onboarding, particularly on the community side.

And the third factor that was mentioned is the ability to have this multi-level of consent because ultimately consent needs to reside in the hands of the individuals that we are trying to help. But giving those individuals multiple ways to opt in anywhere from just sharing basic demographic information all the way to be able to share sensitive information, whether it’s around the safety and domestic abuse or around two very specific comorbid conditions. That is something critically important. We have seen a measurable impact in our ability to actually use this technology during this time.

PP: Congratulations on the patent and this is a great news. All the very best with that. Let’s talk a little bit about the community partners themselves. You’ve gone out and built this fantastic platform, you’ve got the governance, players, data, consent rights and all of the good stuff that you’ve put in place. What kind of enablement do your partners need to participate effectively in this connected care ecosystem? Can you give us a couple of examples of some of the typical challenges that you’ve had to overcome? I hear, for instance, about the digital divide where you might have the technology, but your communities may not be technologically ready to accept it, either because of bandwidth issues or lack of access to devices. Tell us a little bit about a couple of the challenges that you have had to overcome to build the community of care.

SM: You are so right in that, so it’s sort of as we structured the book. Technology was one of six chapters. And while it’s a critical enabler by itself, it cannot solve for everything. So, of all the other components probably one of the most important one is the governance upfront to be able to establish some of those specific areas of how data is being shared. Also, to establish how consent of some of the other things that we’ve talked about. Then some of the other factors, one being the community workflow is so important. So, we can help those community-based organizations figure out how do they weave this in within the processes that already have. And they’re working on a meeting to comply with. To be able to demonstrate the effectiveness and the value that they bring to those that fund their operations.

There are actually a couple of different things that are really important. One is the building of the capacity. Just because we are able to provide a community-based organization with technology, doesn’t mean necessarily that they can use it to its full effectiveness. So, I think building their own capacity, not only how to use the technology, to weave that in within their workflows, but constantly provide ongoing training is important. This is because often times they have quite a bit of turnover as they rely on volunteers. Those pieces become very important in this journey.

Number two, I think is important is to really help them. Again, this kind of goes into the capacity building to define and measure and use that. The backend reporting pieces of the technology so they can measure their outcomes. And in this case, most of them is the social outcome measures that become really important, things such as time to help somebody to obtain stable housing, to return to shelters, reduce rates, meet requirements, maintain housing assignments in transitional care units, etc., or documentation of a food insecure clients visit to a food pantry partner and adequate food provided to obtain that food. So those things are concurrently important on how useful technology can be to do some of their social outcome measures and how they can actually report on the impact they’re having.

And then one of the other things is, it’s not just funding the technology itself, but that backend digital data environment. You need to be able to enable them to provide you with the information in whichever way they can. Oftentimes we talk about, APIs, FHIR APIs and all the new things to integrate. In this case to be able to just ingest a spreadsheet here, you have to have that flexibility to be able to meet them where they are.

PP: You don’t have to make technology more complicated than it has to be. And yeah, we all like talking about FHIR APIs and so on, but spreadsheet can do a lot of good on its own, nothing wrong with using a spreadsheet. So, Steve you wrote this book and it was published just before the pandemic hit if you had the opportunity to release this book today, what would have changed in the book?

SM: I don’t think much would have changed. The message to me remains the same, that this is a complex, multi-year journey. And if you wait for a pandemic to start, you are probably late. So, you need to start now with a focus on how I manage beyond the pandemic. As we look at our own journey, there is the need to really start with a readiness assessment, to build a plan before you even jump both feet in and to build a connected community of care. You cannot stand up a fully functional and deploy the connected community overnight. Given all the other urgent priorities during a pandemic or natural disaster, you need to start doing this now for the next need. Each market is different and there are likely elements that can be leveraged. There are many things that I would say define a market maturity, things such as access to the social economic data, the willingness, and ability of organizations to collaborate, what and how the local incentives are structured. What is the maturity of the committee-based organizations and how aggregated or distributed they are throughout the community? So first, you need to sort of answer a few critical questions around, are you ready? Meaning that the entity that’s taking this on for the community, how ready is that community? And who do we need to work with first? What should be the measurement framework and what’s the sustainability plan? Because it’s not just getting it started, but then how do you sustain it over time? So not only sort of thinking about that front end component, but the other thing that it forced us to sort of just take a step back and think about is building and deploying it, what are the top three things that you need to consider? I mentioned that this being multi factorial, multi-dimensional, its people, its processes, its technology. And one of the new entities into this equation with COVID-19 been the public health department, needs to be an integral part of it.

Number two is engagement, which is complex. You have new diverse organizations that evolve. Many are small and many are volunteer based. The current challenge is how do you do this virtually and you do need to rely on the broad technology more than you have in the past. And how do you actually manage through staff shortages? As I mentioned, a lot of the community-based organizations’ motto is to rely on volunteers. How do you manage and enable them to manage through that? And finally, the technology and data are essential, it is an enabler. And you need to be able to integrate and manage PHI, not just social determinants of health. So that is why that upfront governance for the data decisions, data use, data sharing workflows is so critically important.

PP: I have to tell you, the book has so much for so many different types of executives within the healthcare ecosystem, regardless of which part of the spectrum you’re on, a private sector public sector, on the technology side, or on the administrative side, or even on the clinical side. There is something in the book for everyone. With your permission, I’m going to borrow some of those ideas in your book for my own work, because there’s just so much there that you’ve put into it. I strongly recommend anyone listening to this podcast to pick up a copy. You mentioned something about whether the pandemic has changed your views on what might have gone into the book. As you know, I’m coming out with my second book, co-authored with Ed Marx, on healthcare digital transformation. We did see a big change as far as the pace of acceleration of digital transformation, especially the adoption rate of telehealth and virtual care models and the shift towards those models accelerated in the immediate wake of the pandemic. Our book was going to come out in Q2, and we had the opportunity to put in some of our observations on what we saw happening in the immediate wake of the pandemic. Steve, thank you so much for coming on this podcast one more time. And for those listening, Steve’s book – Building Connected Communities of Care, is absolutely a real hands on playbook for anyone in this space trying to drive change by using technology. Thank you again, Steve. Look forward to speaking with you soon.

SM: Paddy, thank you so much for having me and thank you to all your audience for the opportunity.

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. Steve Miff is the President and CEO of Parkland Center for Clinical Innovation (PCCI), a leading, non-profit, artificial intelligence and cognitive computing organization affiliated with Parkland Health & Hospital System, one of the country’s largest and most progressive safety-net hospitals. Spurred by his passion to use next generation analytics and technology to help serve the most vulnerable and underserved residents, Steve and his team focus on leveraging technology, data science, and clinical expertise to obtain unique social-determinants-of-health data and incorporate those holistic, personal insights into point-of-care interventions. Steve was the recipient of The Community Council of Dallas’ 2017 Social Innovator of the Year award and a finalist for the 2019 Dallas Business Journal most-admired healthcare CEO. Under his leadership, PCCI was named one of the 2019 Dallas Best Tech Startups by the Tech Tribune.

Steve earned his PhD and MS degrees in biomedical engineering and a BA in economics from Northwestern University. He has been an adjunct professor of biomedical engineering for more than five years and has authored more than 100 thought leadership, white papers, and peer-reviewed publications.

Before joining the nonprofit world, Steve served as the General Manager at Sg2, a national advanced analytics and consulting business serving over 1,200 leading healthcare systems, and as the Senior Vice President of clinical strategy, population health, and performance management at VHA (Vizient Inc.). He has also performed in various roles at the Rehabilitation Institute of Chicago, the National Institute of Standards and Technology, and St. Agnes Hospital System.

Steve has served on the Senior Board of Examiners for the Baldrige National Quality Program and on the Executive Quest for Quality Prize Board Committee for the American Hospital Association. He currently serves on multiple other boards, including DFWHCF, NurseGrid and the SMU Big Data Advisory Board.

Steve is a first generation American and he lives in Dallas with his wife of 23 years and their precocious seven-year-old daughter. He is a data and technology geek, an avid sports enthusiast, world traveler, and a self-taught sous-chef and mixologist.

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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