"For a successful digital journey, health systems must connect with different parts of their organization and focus on the core mission."

Anshul Pande, VP and Chief Technology Officer, Stanford Children’s Health in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “For a successful digital journey, health systems must connect with different parts of their organization and focus on the core mission.”

PP: Hello again and welcome back to my podcast. This is Paddy and it is my great privilege and honor to introduce my special guest today, Anshul Pande, VP and CTO of Stanford Children’s Health. Thank you so much for setting aside the time and welcome to the show.

AP: Thanks, Paddy. It’s great to be talking to you. All the good work you’ve been doing has been well received. Appreciate it!

PP: Thank you so much. So, let’s dive right in. Could you give us a little bit of an overview of the digital programs that are currently operational at Stanford Children’s?

AP: Yes. Our digital journey has been there for many years now. We were in the forefront of what was happening from a digital perspective for pediatrics. Some of the things that we did made us realize very early on how to start investing in terms of thinking about how to do remote monitoring, how to get the data, and then how to make the clinician’s life easy in terms of being able to use the data that was coming from digital monitoring programs. Right now, like everybody else, telehealth expanded considerably for us. And the work right now has been around ensuring that we still retain very high levels of telehealth post-COVID. There’s a massive group behind the scenes to understand what happens post-COVID and what will be the barriers for us to stay at high levels of telehealth. And then how do we eradicate those barriers? Whether they are regulatory barriers, billing barriers or experience and equity barriers. So that’s really huge for us. And then besides just the telehealth and the remote monitoring portion, there’s a ton of work going on in terms of process improvement and process optimization. Also, new business ideas are emerging in terms of how we use digital to take care of patients in a different way and to integrate and connect and attract patients from all over the country, if not the world, for things that we do better than anybody else. And after that, once they have had the procedure to be able to take care of them remotely while their local physicians take care of their day to day needs as the case may be.

PP: Being a children’s hospital your population is a little bit different from adult populations. What makes your population unique when it comes to enabling care, using telehealth and remote monitoring and other digital health tools?

AP: Yeah, one of the interesting things is that kids overall are healthy. So, all the things that we as adults have that are usually tied to how we take care of our bodies or did not take care of our bodies or genetic factors, kids usually don’t see that. So, the biggest challenge is that the end for us is really low. I’ll give you an example here. We’re working on a program to be able to do electrocardiograms at home and we could give that machine to a parent and say: “you get us these images remotely.” And the end for that program is probably twelve or fifteen at most in a year. So the programs are really unique in terms of the size which also makes it more complex because the biggest challenge we have faced is that a lot of the devices are really, especially on the home monitoring front, not made for kids because the financials don’t work out for the monitoring companies to develop them. So, we are kind of an afterthought, which makes some of these things even more challenging for us to build, design, and develop.

PP: It’s interesting you say that in many ways, even though your patients are children, the users of the technology maybe the parents. You’re designing both for the children and for the parent and that makes it a very unique dynamic I imagine.

AP: Absolutely and it’s a fidelity issue too. So, if you think about just a simple thing as a weighing machine, the fidelity we’re looking for is a newborn where we’re looking at grams of fidelity, not pounds of fidelity as an example. So, that’s interesting and challenging itself. And then to ensure that a parent can handle that and then the data can be sent from a remote device back to us. So, yeah, definitely some very unique challenges in terms of getting all of those pieces to work together.

PP: Let’s talk about the technology itself. In your role as the CTO, how do you go about assessing your technology choices when you’re implementing digital programs? And what do you see as the role of the enterprise IT system, the EHR system as an example in your digital roadmap?

AP: It’s not just the EHR, probably five or six core technologies are our basis for almost everything. And any time we have a unique problem that comes from our business or from clinicians to say: “look, we want to do X,” one of the first things is to say: “okay, how do we design for X and how do we solve it?” But more importantly, with the solutions that we have with us, whether it’s the EHR or the ERP system or our telehealth platform is to say: “can these things somehow provide that solution?” And then the next part comes in, say, if the answer is no, then who can do it? At that point, it’s buy versus a build decision and in a lot of cases it is: “yes, we think this vendor can provide the underpinnings for it, but we may have to build a brand-new connector that has never been done before.” But the thought process again is use the core technologies that are available today with partners that we have had long relationships with or find a new partner and then subsequently looking at what we have to build in-house by our own developers.

PP: Let’s talk about a specific case. Today, EHR systems have evolved over the last several years and they now offer a lot more functionalities that would be considered digital functionalities. So, when you’re left with a choice of using a “native capability” from your core EHR system, is that your default or do you look at alternate solutions that may be best in class standalone solution that after all you’re in Silicon Valley, there’s no dearth of standalone solutions, innovative solutions. How do you make those tradeoffs? Where do you begin? Could you walk us through a little bit of the thinking of when you come to this kind of situation?

AP: Absolutely. I’ll preface with an example that we just brought online a few weeks ago. One of the things we were struggling with telehealth was that the whole structure around telehealth was built on a patient getting a message through the patient portal, which means that they have to have an email. And one of the things we found out from our patient community was from an equity perspective, a lot of people have smartphones, but not every smartphone owner have an email address. So, how do you ensure that you can still send a telehealth visit information or a starting URL on text. So, our answer is, well, let’s go to the EHR group and find out. Have they done something like this before? Is there a solution that they have available? And the answer is no, they don’t. I said, okay, let’s go to our telehealth group and find out if that vendor has a solution for it. And the answer was no, because if you think about it, the vast majority is using email as a starting point for a conversation, including you and me talking about it today. And then we start saying ok, we have to send text. Let’s figure out with our text messaging system provider. And they said, yes, we can, but I need this information from you. And finally, we ended up creating our own bridge. Within EHR today, a provider can say, I have a choice to start my telehealth visit by sending a message to the patient and their families via email or via a text message. That required all of that work to happen and some amount of development from our side to actually make it into a reality.

PP: Wow, these are some of the assumptions that we live in. I would never have thought that you could have a section of your population that owns smartphones but does not have an e-mail ID that is just simply beyond my thinking at least. But it’s very illustrative and informative because implementing digital health solutions, from everything I hear, is about all these small things. And you’re trying to cover everyone in your population not just sort of a section of your population and you have to take care of everybody. Coming back to the topic of the technologies that you talked about, the fact that you’re looking at four or five technology platforms as the core, including the EHR platforms. When you talk about digital experiences and creating the digital front-end experiences, there is a lot of tools that either are native to EHR or you’re getting it from the outside or you’re building it yourself. What about the back-end infrastructure that needs to be in place for all of these solutions to work well, work seamlessly for the user, whether it is a caregiver or a patient who feel like this is all intuitive, easy to use and is working.

AP: Yeah, that’s a huge problem. When we started on the telehealth journey several years ago, one of the things we were realizing very early is that this is the first time we are actually going out of our comfort zone of our clinics and our hospitals where we could actually manage that experience. We were managing the network. We were managing the device. We were managing prioritization even within the network to say this traffic should go first and we were reaching to a point where we don’t control half of the journey. We absolutely don’t control the patient’s device. We don’t control what network they are on. We don’t control how buggy or busy that network is and how many other things are running on it. And so, there are really two thought processes out there around solving it. One is on the core infrastructure side. It’s like, what can you do to make it better? And how do you solve that particular problem? And we did a lot of work on our own infrastructure side to say, okay, how do you scale up? What happens when you have to have instead of 20 visits a week to thousands and thousands of visits happening a week. Can your network and your substructures actually scale up to it? But then the second part was a conversation with the software vendors to say, how do you handle network drops? What happens when a patient moves from Wi-Fi to a 4G to a 3G? And how do you gracefully handle that experience for a provider as well as a patient? Because there’ll be frustration on both sides. If you’re not able to have an optimal experience, a lot of work went into just understanding the differences in terms of how the software layers are designed.

And it led to us actually changing our telehealth platforms midway through COVID because we saw one platform performing much better than our existing one. But those are things you have to continue to do there. There are software companies that are leapfrogging each other, and you got to take advantage of it. And it’s more so than ever in the virtual cloud space where the speed of innovation has increased tremendously. And at the same time, the options that are available are more too.

PP: Let’s talk about some of those emerging technologies. What excites you now? Both when you talk about the front end, that is the experience layer and at the back end, which is that the infrastructure layer?

AP: Front end there’s been quite a bit of work, I think on the device side we were super excited with our partnerships with Apple. They’re doing some really interesting things, including dropping their device prices. That makes it more palatable for us to be using them within our systems. We are super excited with what we are doing with Zoom on the telehealth side. They have really created a platform that has not only caught the public’s attention, but it’s actually very usable, scalable and robust from a telehealth perspective. We are also looking at a number of groups, whether it’s “Automationanywhere” or “Uipath” or “Oliveai” which provide different frameworks for RPA and AI-based RPA which is getting to be very exciting. And then some of the things that are coming from Twilio Amwell in terms of the patient engagement side and the connectivity with the patient across multiple platforms is super exciting.

PP: What about voice? Are you using voice in any meaningful way?

AP: That’s a good one. Voice has been something that we are still looking at to see how it plays out. It is one of the most interesting things of the population we are in. So, there are two languages that really dominate the market. We are in English and Spanish. But then right after that we have another 30-40 languages where we have populations from all over the world and therefore are just as important to communicate with the patient and have that conversation. And that’s the piece where voice has become an interesting conundrum for us to solve. Is that do we bring an interpreter most of the times into the conversation or is there a better way of handling it? We haven’t really solved that problem yet from a communication perspective. So, it’s an ongoing issue and journey in terms of how we are pushing and prodding our software providers to say, how are you going to help us solve this part of the journey. It is really important to actually have that meaningful communication between the provider and the patient.

PP: Yeah. What about the risks? Now, we talked about all the companies that you mentioned, some of them are very mature at one end of the spectrum. The others are very young companies and, in many cases, possibly seed funded. And it comes with the challenges of financial and technology risks. How do you manage them?

AP: Yeah, that’s a good question. I think it goes into part of when we are doing the selection process, we are looking at understanding will these companies be sustainable? We are not innovation harbor where we actually provide the seed funding and stuff like that. Several of our partners are doing it and great organizations are doing it. Cedars have a phenomenal program. Providence has a phenomenal program. Cleveland has had a program for a long time around it as well. So, that’s not our M.O. We are not looking for it unless it’s a very unique one-off solution to be looking at that earlier stage. But that comes into the conversation when we are selecting a partner to say: “what’s your sustainability like? Can you actually continue to support for multiple years and mature with us?” Especially if you’re looking at an emerging area. And there are conversations around, what is the financial stability or viability of the organization? What’s the excitement level of the market around it too? So, all of those things get into that decision-making process for sure.

PP: Alongside these kinds of risk mitigation aspects that you just talked about. What about the financial side of it? Have you changed the way you look at building business cases for these kinds of tools, considering where you’re headed as a digital first or predominantly digitally enabled organization? Are there tradeoffs you need to make today from a strategic perspective as opposed to a hard ROI? Has anything changed?

AP: Yeah, that’s a good question. It has changed a bit. So, COVID has done a few things. One, it has allowed us to experiment much more rapidly. It’s also allowed us to fail much more rapidly and move on rates or ‘fail fast and get comfortable with experimentation.’ And that’s been wonderful. Without those two things happening, I don’t think we could have made the number of useful changes from a technology perspective in the organization. Regarding the ROI piece, I think that’s the other interesting thing. Certain things are now considered obvious and part of how we need to run our business. In fact, our entire executive leadership team is very gung-ho on digital first across the board rate. So, they have bought in. And our boards are bought in. And this was before COVID from our own journey perspective. So, the discussions are slightly different. I think the discussions are not always about ROI. And when ROI comes into play there’s no question about it. But ROI comes into play when we are looking at a replacement of X to Y. I think in other cases, ROI’s are discussed when we are looking at a brand-new idea to say: “Ok, if we have to really push this idea, how much does it have to scale before we are actually making money on it?” So that gives you at least a clear line in terms of what the adoption has to be, what the usage has to be for something to be actually meaningful and valuable, which is always a good thing from a business perspective. But here we are experimenting a lot more and there’s a lot more thought to saying if it is a good idea, let’s invest in it.

PP: Yeah. And you’re right there in the middle of Silicon Valley where you have ample opportunity to experiment with new technologies. If nothing else, I’m sure there’s a lot of people who want to experiment with you. We’re coming up to the end of our time here. I’m sure this has been fascinating. I want to leave you with one last question here. If you had to share one best practice with your industry peers who are on their digital journeys, what would it be?

AP: That’s an interesting one. I think engagement is important. So, connect with different parts of your organization and come up with a single mission for your organization. That has helped us tremendously. It gives a lot of clarity when your CEO is providing the vision of what digital means and what digital could look like for your organization. And it also helps you through the peaks and valleys. It’s a long journey and you will have peaks and valleys. But having that commitment from the very top helps tremendously with that.

PP: We’re going to have to leave it there. It has been such a pleasure speaking with you. Thank you so much for setting aside the time and all the very best for you and your team.

AP: Likewise, Paddy. It’s great talking to you.

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