"Digital health will change the mindset that care delivery can happen only in clinics"

Nick Patel, MD, Chief Digital Officer, Prisma Health in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “With digital health we are getting out of the mindset that care can be rendered only in the office”

PP: Hello and welcome to my podcast. This is Paddy, and it is my great privilege and honor to introduce my special guest today, Nick Patel, Chief Digital Officer of Prisma Health. Nick, thank you so much for setting aside the time and welcome to the show.

NP: Thank you, Paddy. Great to be here.

PP: Prisma Health, I believe, came about as a merger of a couple of different health systems. Would you like to take a couple of minutes for the benefit of our listeners to tell us a little bit about who Prisma Health is?

NP: Yes, sure. Prisma Health is the largest, most comprehensive non-profit hospital in South Carolina. It was formed about three to four years ago when Palmetto Health, which was located in the central portion of South Carolina and Greenville Health System in the upstate, merged to form Prisma Health. We span over 50 percent of the state. We have 18 hospitals and about thirty thousand team members, and were actually the largest private employer in the state of South Carolina, with 330 ambulatory practices and about 45 percent of South Carolina live within fifteen minutes of us. We also have two comprehensive stroke centers and two affiliated medical schools as part and I actually did my residency training here with them.

PP: You’ve been with Prisma Health in its previous form for a long time, so, you’ve really seen this organization grow. Fantastic. So, Nick, you’re currently the Chief Digital Officer. What does that mean? What are your responsibilities? Who does the role report to today?

NP: It’s an interesting journey to get to become Chief Digital Officer. I was previously an internal medicine physician and I’ve been practicing for 17 years. And through my 17 years, I’ve seen us transform from paper to EHR and the disruption that caused into what we’re moving into now digital health and digital transformation. As my career grew, I was asked to be on different committees when we were rolling out the electronic health system and I eventually became CMIO for the medical group. And as we were going through this transition to becoming Prisma Health, the CEO asked me: ‘So, Nick, what would you like to do next? What should you be doing in Prisma Health from a digital innovation standpoint? I had attended HIMSS, the big healthcare conference that happens every year, and Hal Wolf, who was the CEO of HIMSS, had a presentation and keynote that he was giving. And I got a chance to have dinner with him the night before he had invited a small group and he leaned over to me and said: ‘Nick, what do you do and what do you see yourself doing in the next couple of years? And I described that no one was really focusing on patient experience and access and digital transformation. CMIOs really just focus on informatics and day-to-day activities of EHR and optimization. CIOs focus on infrastructure, hardware, networking, and making sure we follow security guidelines and things of that nature. But there was no one in between that looked beyond the EHR and hardware infrastructure. And that’s how Wolf talked about this role called the Chief Digital Officer. How that person will be instrumental in truly transforming delivery, that is patient focus, improving access, taking digital health, remote patient monitoring, artificial intelligence and other things to the next level. And so, I pitched that and wrote my job description and gave it to the CEO and they really liked it. And after some wordsmithing, I came to an agreement of my role as Chief Digital Officer and Vice Chairman for innovation. Currently, I answer directly to the system CMIO. But if you look across the country, the role has different reporting structures. For example, a CDO can in a lot of places answer directly to the CEO where they shape the true strategy for a health system. Similarly, sometimes they answer to the CIO, the chief or the chief administrative officer. So, it just really varies.

PP: Yeah, that is a fascinating story of how you saw the future through a chance conversation that you have with somebody. And that’s so interesting. As you are the first Chief Digital Officer for this system, could you give us a brief overview of the digital programs that you’ve rolled out in your role at Prisma Health the last couple of years and maybe give us an example of a program that has made a significant impact for your organization.

NP: Before COVID, we had already started looking at where we wanted to be when it comes to patient access, how we wanted to hold up Prisma Health around virtual visits and things of that nature. And the first project that I did as Chief Digital Officer in conjunction with the system CMIO was around online scheduling. So, when you bring two healthcare systems together, there is a lot of things that need to happen. Every system did their protocols and workflows differently.

We also needed to get to know each other as providers, who we were, what specialties we have and where do we have them. So, if you were to look at our web sites on both sides prior to us becoming together, it was disjointed. We have doctors in rural locations, we have doctors listed that were not even here anymore, things of that nature. So, what the first thing we want to do is produce a source of truth as our provider directory so that a patient can go online and find the right doctor for them. And so, if they put in diabetes and say, look at all the doctors in primary care internal medicine and family practice that specialize in diabetes, you might want to then put your zip code in, you’ll find the person closest to you.

And that helped for many reasons. Number one, it helped us as a system because we needed people to know who we were and our assets and what services we provided. It also helped us internally to setup a database of all our providers, where you had pictures, videos, testimonials, we had our ratings, our credentialling and all of that in one singular place. I guess my evil plan was to say that we now have a profile on every single provider. So, it’s like a user profile no matter what digital asset or virtual asset we then built, that same picture, same profile moves with that person. So, that was foundational for me. I think it obviously helped us come to some realization if we’re going to focus on patients and patient experience and we need to come to standardize rules around scheduling templates and all those things. So, that was part of that project and we’re live and it’s doing well. We’re now a year and a half into it, but still we got a lot of work to do to shape that. So, outside of online scheduling and video, some of the other assets that has really helped during COVID is automation and chatbots.

We had partnered with a company around different types of programs, hypertension programs, diabetes, post-operative care, and that automates the process and says: ‘hey, you are hypertension patient, I noticed your last three blood pressure readings are high. Have you been taking your medicine, yes or no? Have you been fine? Are you having an appropriate healthy diet? Yes or no. Are you doing X number of steps?’ So, it’s like engaging the patient at home as a little digital kind of nudge in between those office visits of how you are doing. What we’re doing with that is taking it to another level and adding remote patient monitoring. So, we partnered with the company to have connected devices that are fully connected to a person that literally puts on and I start getting data coming into our EHR and we’re setting a threshold. So, Paddy, if you’re my patient, you have hypertension, I’m going to put you on a blood pressure cuff. Just check your blood pressure once or twice a day to start. And if I on the background have setup a threshold, so if I want to know, when Paddy’s blood pressure goes over X over three consecutive times, then a chatbot is going to ping you saying: ‘hey Paddy, your blood pressure is going up.’ Now it’s going to really engage you and ask you some questions and if you answered those questions three times in a negative light, then a care coordinator or a Pharm D or nurse will call you and say: Paddy, what’s going on? And you reply: ‘well, I didn’t get that medicine, some were too expensive, when I got to the pharmacy, I figured I’d talk to Dr. Patel when I see him in three months. And the coordinator replies: ‘no, let’s change it now. So, we don’t want three months of higher blood pressure for you.’ So, this is the thing about digital health that we’re trying to do is to get out of that mindset of the only time your care is rendered is in the office. Care should be rendered at any time at home, especially in between office visits, because that’s where you live. You don’t live in my office. I can’t control what happens outside the office. And being a practicing internist for 17 years, I could tell you that how many times a patient sits on ‘I didn’t want to bother you, I figured we’d talk in three months or six months or next visit.’ You mean to tell me your blood pressure has been this high for that long and your sugars have been this high for that long.

Instead, me proactively knowing as your caregiver that how you’re doing and pinging you and keeping you engaged, go for walks and motivating you and gamifying that if you keep doing this to another 5000 steps and you going to get 10 percent off on your next visit here. You’re going to get 20 percent coupon devoted to your local grocery store, all these sort of things start to tie together. And that’s what I’m trying to achieve here.

PP: That sounds very, very comprehensive. And everything that you talked about, Nick, are things that I see other health systems also investing in. And, the point that you made about scheduling and access, that is by far seems the number one focus, especially when in the wake of COVID and in-person visits practically came to a halt. And now it’s probably going back a little bit and you’re getting people back within your clinic, facilities, and so on. Specifically in response to COVID, did you launch anything that was going to help your patients and your patient populations?

NP: Yeah, in the second week of March we had already, like many healthcare systems it was a very tough decision, stopped elective surgeries. As you know, surgeries specifically are huge revenue generator for any healthcare system. So that was a big decision. But then we started thinking about, well, if we are doing that, having patients come into their ambulatory visits also have a very high risk. We already noticed that our cancelation rates are going up through the roof. People are scared to come in. They saw what was happening. They were trying to follow the rules, distancing and wearing a mask and handwashing and as you remember, Paddy, in the beginning, it was chaotic. New information was coming out on a regular basis and was very fluid in the beginning. So, I reached out to the president of the medical group and said: ‘we need to virtualize all ambulatory visits right away.’ So, I came up with a workflow, worked with the team of how that would work. Essentially take the scheduled patients, flip into video visit or an audio visit. And at that time, there was still no clarity on reimbursement for those. But we knew that it was important because the last thing you need is to have patients who have chronic disease exacerbate and then go to the ER or be admitted. Its a last place you want people to go. And so, we found that it was important to be able to provide continuous care to our patients and virtualize that. And if you look at last year, we must have done about 20000 thousand virtual visits. Since March, we’ve done three hundred sixty thousand virtual visits at Prisma Health. And the thing about COVID is its pretty standard, that is fever, cough, shortness of breath, primary symptoms, secondary symptoms, loss of taste, smell, etc.

We wanted to make sure that when we screen patients, they wanted to know should they get tested, they didn’t have to call a provider and get the same questions that a CDC guideline or WHO already had out. So, we worked with our chatbot vendor and they had produced a COVID chat around COVID screening. And since March, we’ve had one hundred and ten thousand people used the COVID screening chat and it puts you in three boxes. Green says, you’re fine, you’re worried, here’s the education on how to stay well. Yellow says that you have some primary symptoms of COVID, but you may just have a common cold. You may have something else going on. Let’s do a virtual visit. And then red says you have all three primary symptoms plus travel, which is not an issue now, but it was at the beginning. You need to get tested. And here’s our community testing sites where you can go and get tested.

So, it had been very successful and then we expanded that because we also had to screen our own employees. So, instead of having screeners at every door, we rolled out a digital badge. So, one can do an abbreviated screen on phone. It gives you a green pass with a checkbox similar to what you would use to check in with something like an Apple Pay. And it would have your name, date and have the timestamp and it decays. So, after 12 hours, the pass goes away and in your next shift, you have to come and do it again. And obviously that gives us data on which of our employees are going to the red box, who needs to be tested, isolated and business health reaching out to them. We also had the demand from the community as COVID later on, in the summer, people were trying to return to work. A lot of employers wanted their employees to come back with a doctor’s excuse saying they’re OK to come back to work. Well, again, same process, but now we took that shot and you enter your name, your email address and if as long as you have pass, you get a digital email white labelled to you which says you are now clear to go. Plus, it has links and education is part of that e-mail. So, there are lot of things like that that we did. The virtual visits, both asynchronous and video that we did as Medicare and payers finally came up and gave us a final rule and reimbursement, they registered it back to March 1st. So, we have three hundred sixty thousand virtual visits and we got paid for that historically we wouldn’t.

PP: In the order of magnitude of the change, the 10x increase in visits seems to be a very common story across the nation. Whoever I talked to has seen that kind of volume changes. In your case, it seems like you already had a virtual visit, telehealth program in place and you have to scale it. But I’ve talked to others where they had practically no virtual consult and they had to overnight switch to a virtual care model. When you have this degree of change and I often hear this expression that what we plan to do in five years now, we’ve had to do it in five months and things like that. What kind of a stress does it impose on the system from a technology, process, people, and change management training standpoint? Can you talk about the experience you went through in just getting this up and running and getting it right?

NP: Yeah, I was pleasantly surprised. Historically, there are a lot of steps to take from change management, governance, making sure Infosec and ITS, informatics, clinical leadership, all are aligned. And it takes time and usually as you go from one to the other and other, here it was linear and we did it all together. So, we had a meeting around changing ambulatory visits to virtual, that workflow from a technology standpoint, from a provider standpoint, from leadership standpoint, or a revenue cycle standpoint, everybody was on the call. Everybody did their part. And that’s how we were able to move this so quickly. So, yes, there was a lot of stress, but there was also a lot of teamwork, which was very great to see and has made us understand how you can really streamline the process in the future by working together in a linear fashion versus a hierarchal manner. And we had challenges like anybody else because not every single computer within Prisma Health was telehealth ready. Not every monitor had a camera built in or speakers or mikes. So as everybody saw there is a massive shortage of web cams and speakers and mikes as everybody’s trying to buy them. And we had some of that. When I had a one-on-one with the CIOs, I was like: ‘hey, maybe from now on, let’s not skimp on ten dollars and twenty dollars when we can get an integrated camera that has mike, speaker and all in one computer or desktop that we have. Instead, just let’s make sure that any clinic asset or computer is telehealth ready with these basic things.

The other thing was as we became Prisma, we still had digital disjointed network infrastructure. So, you’d have different SS Ids as you went from one system to the other, from university practice to non-university practice. And then with varied access, we had to quickly make sure that we had people with laptops and iPads that were fully connected in our secure network so, they can render care. And we needed to make sure, as all these providers from Monday to Friday and even weekend had high quality broadband access for delivering care. So, some of that was also you had to start to think about. You had to think about documentation. You had CMS and other set documentation that they had to delineate between an office visit and a virtual visit and in an audio visit and a video visit and at the station statement that went with that. So again working with informatics and educators, the revenue cycle and coding, billing and compliance being part of that and say: ‘Nick, this is what needs to be in every note and this is how it needs to sequence out.’ In the beginning this was a massive statement but then it became very narrow because we overshot and every health systems wanted to do everything they could, to make sure they got reimbursed for these visits. So, they put more than they needed. And then the questions from billing and coding of how do you do a level four or five visit when you don’t have components of a physical exam? And how do you maximize things that you can’t do? How do you make sure you document the time when you still have a time requirement? So, it’s a lot of work. Since March, my team and many others have been working 12 to 14 hour doing this and operationalizing this. At the same time, we continue to grow and say, we need to expand our RPM program, we need to expand, enhance video visits, and we need to expand chatbots. So, you can’t become stagnant because you just don’t know what’s going to happen with COVID. I think we’re in this for the long haul for at least another year. And so, we have to prepare as a health system to continue to innovate, to take care of our patients and be ready for whatever the next wave is going to happen.

PP: In that context you’ve seen a dramatic shift towards the virtual care everybody has. There was an extreme shift in the immediate wake of the pandemic and all the recent anecdotes and the data seems to indicate that there’s some degree of pullback and the traffic is flowing back into the facilities, maybe for pent up demand, maybe for procedures that cannot be put off anymore. Well, for something that you can’t continue to do on a virtual basis. So, for whatever reason, I don’t know if we have reached an equilibrium point in terms of the share of virtual care in the overall context of care. Could you talk a little bit about that? Where do you see some kind of an equilibrium in your own system? And if not, how long do you think we’re going to wait to see that? Because you’re making a lot of investments and these investments are not going to pay off immediately. Some of them are there for the longer term. How are you approaching this for the longer term?

NP: Yeah, it’s interesting. We actually try to get a pulse of our providers on how things are going on a regular basis. We know that our number of virtual visits have declined, and people are coming to our practices again and they want to get out of their house and see their provider. We’re also finding that a lot of social determinants have come to light that we did not typically think about, like technology literacy, broadband access, hardware access. A lot of the older or elderly patients who are higher at-risk have flip phones. They can’t do a virtual visit. They don’t have a desktop. They’re technology challenged. So, you still have to have a hybrid approach. You can’t just force everyone to use this. So, we had never closed our offices. We still have people come in. There are things like procedures that you have to do, minor procedures or lacerations or abrasions or an abscess or things of that nature. You still got to be able to do some hands-on care for patients.

So, asking the providers of where do you see this going post COVID or the new world post COVID, we find if reimbursement in the federal regulations and policies remain the way they are about 20 to 30 percent of all ambulatory visits will flip to virtual. And that does a couple things. One, it allows you to see patients who have appointments because they have transportation issues who live in rural areas. Helps you with outreach, but it also lets you see people more often. So, instead of seeing someone every six months with chronic disease or three months now you’re able to check in on them digitally and see how you’re doing, either through RPM that seamlessly coming or checking in through video.

And so, I think that’s kind of where we’re going to be. But do I think we still see patients. I’m still a practicing doctor and I can tell you on Monday, Wednesday, I saw most of my patients who wanted to come in and see me. And obviously, all the protocols are there and everybody was wearing masks. I think that’s where we’re going to land. What you learn about this is, as a doctor you have an average panel of fifteen hundred two thousand patients if you want to try to keep up the volume. But with true movement to population health, one doctor should be able to take care of 10000 patients using APPs, care coordinators, pharmacies, social workers in the community. And be able to take care of diabetes on a larger scale or in a community scale versus checking in one patient, checking out another patient because we don’t have enough doctors to go around. I mean, if you look at the Agency for Healthcare Research and Quality and CDC, in 2015 we did about a billion encounters. Nine hundred and ninety million encounters. Sixty one percent of those had chronic conditions and fifty one percent of the billion went to primary care. And there’s not enough primary care to go around.

And so, you have to start thinking about how you develop the next generation of care delivery. And this has been in discussions since the eighteen hundreds. My friend showed me an article that came in 1879 in Lancet, which was in a a peer reviewed physician journal, it talked about using telephone to reduce unnecessary office visits. And I think in 1925 it came out in Science Invention magazine of how to use it. So, I think that clinically we have some good momentum around that and it will stay for long post-COVID.

PP: Yeah, it’s interesting you mentioned the model where you do more with one doc, surrounded by a team of professionals from different disciplines. That is a in fact the model that many smaller countries around the world are actually practicing. The density of doctors to the population is nowhere near as close to where we are here in the United States. So, this is a problem. They’ve lived for a really long time and they’ve already gone down the path that you just described.

And I feel like the technology is the next stage of evolution in the model where you are able to achieve more through technology enablement and deliver more care, take care more people with the same group and the same number of individuals. So, that’s a whole interesting another conversation, I guess. So, Nick, in this show, as we discuss digital front doors and you have describe many of the initiatives that go into a digital front door program on a point of view of access in particular, and then you map out the patient journey. You identify the high impact touch points and you use digital solutions for implementing those care models. What would you say today are the high impact digital engagement touch points for a typical patient journey and more so in the context of your patient population? Could you share your thoughts from that?

NP: Yeah. I think that patients want a retail experience. They don’t want to have to fill out paperwork everywhere they go. And we’re good about doing that in healthcare. I think part of it is how do you use automation? I think for me, as much as we can automate processes in healthcare the better. As my friend on a previous call around artificial intelligence and medicine said, how do we take the robot out of the human? We do a lot of things in healthcare that are just robotic, that don’t require our clinical background and training to do those activities. And so, from a digital front door standpoint, how you virtualize the whole intake process and how does that data become singular? And that’s where it comes down to data is extremely important, discrete, non-siloed data that is continuous throughout all systems, no matter which when you’re in. And so when you look at one patient, you see a true 360 view. Doesn’t it matter if they’re calling through a contact center, through a CRM process or through an office or virtual or through a campaign in the community, data is singular. So, I think you have to concentrate on is thinking about how do you modernize your data systems? You know, we moved away from hard assets into the cloud. We partnered with Snowflake around cloud computing and storage, which has really helped efficiency. And there’s a lot of different things that we’re trying to do, standardize workflows and protocols, as you mentioned earlier, so that everyone is singing off the same sheet of music.

And that helps the patient. It brings the cost down and the experience is improved. I would say that having automation as part of your process and your digital front door as well as care is very important, through either chatbots or other means through your CRM. We are working very close with our CRM partner on some of these items.

PP: Yeah, interesting. We do see that in fact, we’re doing a lot of work in this space where we are using the CRM platform, helping the health systems use the CRM platform to drive a multi modern multi-channel communication protocol, which is driven largely through automation. And that’s exactly what you’re talking about. We are coming up to the end of our time Nick. I just wanted to take the last minute or two that we have to ask you a couple of questions. If you had one best practice that you would like to share with your peers in the industry, what would that be?

NP: I think the biggest advice I would give to anyone who’s going down this journey is don’t start with the technology, start with the need. What is the problem you are trying to solve? And then see how technology can help you get there. The technologies that you have must be an interconnected ecosystem that is efficient, intuitive, and then take advantage of automation driven by data, that is very important. I think what healthcare systems make a lot of mistakes is that they start with technology and try to solve a problem that’s not where you want to go and you want to keep it patient-centered, provider-driven is extremely important. So, that’s my key takeaway from our journey so far in this world.

PP: Fantastic. That is such a fantastic note to close this conversation Nick. Thank you so much for that and setting aside the time and talking to us and sharing all of the insights from your experience. I wish you all the very best.

NP: Thank you, Paddy.

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