"In any healthcare organization, integration of third-party apps with your digital solutions can either make or break you."

Ray Lowe, Senior Vice President and Chief Information Officer, AltaMed Health Services in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “In any healthcare organization, integration of third-party apps with your digital solutions can either make or break you.”

PP: [00:01:08] Hello, everyone, and welcome back to my podcast. It is my great privilege and honor to introduce my special guest today, Ray Lowe, SVP and CIO of AltaMed Health Services in California. Ray, thank you so much for setting aside the time, welcome to the show.

RL: [00:01:26] Thank you for including me today.

PP: [00:01:29] Thank you. Can you tell us a little bit about AltaMed Health and the patient populations you serve?

RL: [00:01:40] Sure, I’d be delighted to. So, I’m Ray Lowe, CIO and Senior Vice President for all of the health services. I’ve been with the organization for three years and in this time period, we actually have completed a ‘digital overhaul’ of the enterprise, including technology applications, patient engagements. AltaMed serves over three thousand patients at over 50 locations and the greater Los Angeles and Orange County areas with over one million visits per year. We provide services to the Medicaid, underserved populations that are primarily Latin, multi-ethnic, and many of those are 200 percent below the poverty level and 40 percent are pediatrics. Some of our services include primary care services, women’s services, pediatrics, HIV AIDS outreach. We also have programs for all-inclusive care for the elderly. We also have two other companies. One is the ALtaMed Health network, which is a strategic ______

again, focusing on Medicaid internal product, as well as a managed care organization known as Alterra.

PP: [00:02:48] Thank you for that background. I am obviously interested in learning about the complete digital overhaul that you referred to, and that will be the focus of our conversation. But before we jump into the digital transformation journey and AltaMed, I understand that it is also a pioneer in the use of the patient centered medical home concept, the PCMH concept. Could you talk a little bit about that experience and how that has worked for your population?

RL: [00:03:22] Sure. So, I just started PCMH or patient centered medical home until it actually started this in 2011. So, you have a bit of time working on this. We started with our pediatric populations in joint co-operation with Children’s Hospital, Los Angeles, and we also utilize the PCMH approach on our senior services. At its core, what PCMH is, it’s a way of coordinating care for our patients. It also means adjusting our processes and care to treat the whole person. Within our PACE program, we have nurses that manage patients ensuring they receive regular treatments, required medical equipment, special referrals and other type of clinically related activities. We also provide PT/OT, dental, and socializations to help them vibrant. We expanded this even further, including interdisciplinary care, which is our social aspects and social determinants of health. So, for our PACE seniors, our teams work to address both the clinical, the social interdisciplinary and any type of SDOH things that can impact them and their overall well-being.

PP: [00:04:35] You’ve been practicing this since 2011, so you would have been one of the pioneers in this concept. I imagine that you have a wealth of data and you’re utilizing that to drive improved outcomes for your population. So, you mentioned about coming out of a three-year digital transformation, digital overhaul. Can you tell us a little bit about that? What were the top priority areas for that program and what kind of programs are currently operational at AltaMed?

RL: [00:05:10] Yeah. Our priority is really providing quality care without exception. And from a digital health perspective, that really means patient centric care where, when and how they want it. AltaMed provides care for essential workers. Many of them are low income and underserved communities, this is a patient population that has been inadvertently left behind. I would say due to the digital divide that does exist out there. As we plan our strategy, first and foremost, we want to have a global strategy that provides care with flexible walls both inside and outside of our brick-and-mortar facilities. The second thing that we do with our digital health strategy is that we leverage our Epic MyChart. We call it MyAltamed portal for patient interaction and messaging. We went live with Epic in October of 2019 in a 10-month implementation cycle. And the interesting thing is we’re barely five months ago from a pandemic yet. And the digital solutions that we built – telehealth, remote patient monitoring, patient engagement strategies – are all centered around MyAltaMed in MyChart of Epic. So that we can have the rich clinical information and stay in good contact with our patients around them. In March of last year, if you draw that as a starting date, we had on our roadmap the virtual health, the tele visits and RPM and my diet partner and we were evaluating who would be possible candidates that we should be looking at. And for instance, on the RPM side Vivify, Livongo, VitalTech, McKesson and other ones that we were having conversations with, we had not selected one. And then even in terms of the televideo, we’re having conversations with American Well, Vidyo, Cisco extended care. In other words, what would be the right solution for the organization?

In our digital journey, we learned quickly through the pandemic that we had to be able to deliver a televisual platform around that. The third area we’re looking at is transitions of care and managing our patients in the hospitals and beyond our hospitals as a case management. This is all about data interchange and being able to mine the data so that we can have timely data and we can do the proper kind of interventions. A fourth area we’re looking at would be in our women’s services and their pregnancy journeys. What is the type of handheld app that can help on the mother baby journey. Be Babyscripts, be it mommy or others that help our pregnant moms as they’re going through their different trimesters and their wellness checks and then again, continuing expanding our care on the walls for our PACE participants. The pandemic has really reduced the amount of participants that can actually come to our centers. And so, we’re looking at how do we continue to have the seniors be vibrant, receive the same amount of care in a technology supported method. And often you’re dealing now with a population that may not be the most technically savvy, but we want to make sure that they are not afraid of the technology, how to use it. And lastly, again, looking at the wage aspects on the care and helping our patients access to services.

PP: [00:08:45] Well, that sounds like a really comprehensive digital transformation program.

You cover pretty much everything that would be considered a high impact area. So, you talked about telehealth, remote patient monitoring and mobile applications for the populations. The question that comes to my mind is you mentioned that you serve predominantly low-income populations, and you also mentioned the digital divide that is out there. So, in that context, what kind of unique capabilities or unique enablement do you have to plan for and put in place for your populations to get the same access to the same quality of care as anyone else?

RL: [00:09:28] You really hit the nail on the head. That’s one of our most significant challenges, an area that AltaMed strives, which is to be culturally sensitive. Rather, the majority of our patients are Spanish speaking. They may only have a third or fourth grade education. So how do you communicate with them when you start even at the top with Epic systems in Verona, Wisconsin, as we launched our Epic MyChart, our cultural and linguistic folks know the Spanish translation. And so, we work jointly with Epic to really enrich a Spanish translation so that users can understand it more easily. Again, we are working here in East Los Angeles, a very heavy Latino area versus folks in Madison that may have more a Google translation of Spanish, but that’s a big key area around there. The other thing that we’re seeing is there are a lot of folks building apps that may work on an iPhone 10 or something new or maybe an iPhone 8. But when you’re dealing with the underserved and low income, oftentimes they may not have that latest iOS system. They may not have an iPhone 6 or 4 because they can’t afford to get a new iPhone. With this patient population, they’re making decisions on whether they pay their cellular bill or whether they’re putting food on the table or the real decisions they have to make every day in terms of how they spend their valuable dollars. So, when we look at the technology solutions, we require the language diversity, backward compatibility on different types of iOS systems and ease of use. And you would really be amazed to hear that many folks don’t think about it as they’re delivering and bringing things to market.

PP: [00:11:22] Wow. That is something really counter intuitive. Having to plan for backward compatibility. And a lot of us are looking at the next version of the iPhone as opposed to an iPhone that is three or four generations ago. But it’s a very real problem that you’ve described. I think this is what healthcare is all about, making sure that it’s inclusive and it serves the needs of all populations. You talked about a lot of technology choices here and all the different platforms that you would consider Livongo and so on. When you assess technology partnerships in your technology choices for implementing digital programs for the population, what are you looking for? What are the top two or three things that drive your decisions, especially as it relates to digital front door tools and mobile apps and engaging with your populations?

RL: [00:12:18] So we rely heavily upon Epic through either the user groups, what we’re seeing in the App Orchard, because it’s really so strong and sharing the best practices we’re able to learn from UPMC, from Cleveland Clinic, Kaiser Stanford in terms of their journeys. And they make it available so your learning can be faster because they’ve proven what technologies can work. Speaking more about the App Orchard, in any type of healthcare organization, the integration of third-party apps can make you or break you. And further it will tell how well that digital solution will integrate. Granted with enough time and money, you can make many things work, but when you’re doing a digital transformation in a matter of months. And which is really the pace which most of us are going now versus years of kind of playing with ROI and fed and interfaces etc. You really need to be pretty clear that it’s going to integrate very easily, stacking them together just like Legos so that you can turn something on in a couple of months versus looking at maybe six months or eight months later. And part of innovation is failing quickly. So, you can learn around that. And by taking that approach, you can easily see the results before you’re so committed to a program or to an approach. The other things we’re evaluating is now e-console platforms are really becoming very interesting right now in terms of how we help our providers. And we’re looking also ambient voice for provider productivity and ease of use. And then on the patient side, kind of looking at our elders and some of the other areas is can we extend tablets out to them that they’ll find easy to use? And again, kind of addressing that inherent digital divide so that they can be connected electronically to AltaMed.

PP: [00:14:27] One question that comes to mind when you talk about a range of digital solutions that you’re trying to implement is how do they pay for themselves? There is a reimbursement component to it, a ROI component to it, and obviously there’s a cost component to it for the patients as well in terms of the devices or bandwidth access and a range of other things. How do you go about looking at this from a business standpoint?

RL: [00:14:56] That’s a great question because you need to look at why are we innovating? What is the business outcome? There may not always be a financial reason, a financial payback. And when you look at the quality and doing what’s right for the patient and so that by extending solutions to them is the right thing to do. Honestly, I would say, again, we went live in October of 2019. And before that, if you wanted to come to AltaMed as an essential worker, you’d have to take a day off. You may have to take multiple buses to come in. You could not auto-register etc. And when you look now in 2021 in January, we offer both telephonic or tele video visits. We provide this with the ability to bring in language translation services to the mom with that kid that could be sick or somebody with the URI, which is very prevalent. People are very concerned and able to address those needs. So that’s really about doing the right thing for the patient, because nobody wants to go into a hospital and nobody really wants to go to a clinic, but you still can provide that care for the patient at the right time.

So, I look at a lot of that. ROI is what’s the right thing we need to do for the patient. How do we need to do about quality as well? You mentioned reimbursement. That’s always a tricky topic because now we’re talking about the feds and how the CMS guidelines are reimbursing or not reimbursing. And that could be complex sometimes. It does affect timing sometimes in terms of what you introduce for your digital solutions. But I think ultimately keeping what’s at the best interest of the patient is where we need to be. And I think the other part of it is when you’re implementing, you need to understand what is the provider workflow change will look like and what will the patient look like? You can put in some very cool digital tools, but if it’s not adopted, you won’t be successful with the outcomes you need.

PP: [00:17:08] That leads us to obviously the big question, how do you get people to adopt to it? And at this point, we are not just talking about patients, but we’re also talking about caregivers. What kind of training, what kind of enablement do they need? How do you make them change their workflow or their daily problems? So, this is not new to you. This is a universal challenge across all of healthcare. Can you talk about one or two things that you consider a success in this regard in driving adoption?

RL: [00:17:39] I can use a language and I can use a tele-video as both example, because they’re all very new. Again, if we go back, it was April 8th of 2020, the CEO came to me and he said, give me a video solution. And I’m like we didn’t even have anything instantiated. And then CMS was dropping their HIPAA requirements. It was making it much more open. You could do some video, other areas to address it. But we want to make sure that what we talk is still a HIPAA compliant approach. So, we didn’t expose anything accidentally or put anybody in a breach type of position. So, we actually selected two, which was Doxy and Doximity, which is widely used in healthcare with an eye towards a long-term solution which should be integrated with Epic, launching out of Epic etc. It’s a change moment, right. We got it to work. We try to be the correct flows and templates inside of Epic. We trained the providers and yet there was a lot of confusion because they really didn’t know and patients didn’t understand on personal care going into a black room. It was really very challenging in terms of driving the adoption.

So, what we did is we reset, and we created a digital center of excellence within two of our clinics where they would primarily focus around the televisual experience. This includes language and other requirements that we would have so that we got really good at it. And then we’re able to share those best practices across the other two hundred plus providers in all time so that it’s much more standardized. The other thing I did, as well is that from a training perspective, my training team was certainly conducting a lot of distance training, web training as a norm and we weren’t getting the results. So I said, you need to meet the providers where they are. And we could do Zoom training, Webex training all day, but they’re not quite getting it. So, we really doubled down, tripled down on the hand training with the folks and they had hours working with them. The clinics up there, again, able to be much more comfortable with the usage of the tool.

PP: [00:20:00] Yeah, those are very interesting examples. You talk about innovation; you talk about it few times that you’ve accomplished quite a bit within a very short time given the pandemic and everything. And possibly because of the pandemic in the sense of urgency that created around the implementation of some of these programs. Does the other side of driving innovation rapidly? You refer to it in passing when you talked about failing fast and learning quickly and moving on? So, how do you manage the risks of innovation, especially the innovation that comes to it in the form of a solution that’s been developed by digital health startup? And what is your advice to startups who are looking to engage with you and be part of your innovation journey?

RL: [00:20:50] That’s a multipart question. So, I think it’s actually cited in your book. From an infrastructure perspective, have a sound foundation in terms that you can go ahead and sprint and look to leverage your technology backbone to deliver these resources. There are so many different workshops or data center processing activities hosted solutions that can cause many problems to fail, technical debt etc. And there was quite a bit of technical debt here. I remember I heard there’s a great quote from Warren Buffett that when the tide goes out, you discover who’s been swimming naked.

PP: [00:21:40] Yeah, I’ve heard that one too.

RL: [00:21:44] Yeah, I love that quote. And a lot of folks, that have been ignoring their technology infrastructure, just putting it off, extending the life they were caught when the tide went out. So, the investment of understanding the life cycle and the technology that you’re building. Again, we kind of did almost a wholesale upgrade from our data center to our networks that are happening out there. And part of that is building really strong partner relationships. I selected, of course, AT&T and heavily with Cisco, NetApp and partnerships with Presidio networked connection. And I had to leverage those technology partners. And the thought leadership where I had gaps in my own team’s ability to deliver. But the net sum of the parts just delivered superb results. I like having executive briefing sessions. And again, at Cisco, there’s a girl, Catherine Howe, who’s the director of their healthcare, and we had an EBC with her. And I was putting all of the Cisco products and we went through an exercise that was actually able to determine for what we wanted to deliver, that I have actually made all the right technology choices. And so, I was like, OK, turn the afterburners on, we can go even faster. And that occurred about at the end of 2019. So that was a good way to start from a technology perspective. But then you ask me, what do you share to startups, what would you tell them? You know, there’s so many great ideas and companies that are out there. I manage the risk by having a joint review of my diet partner, Dr. Eric Lee. He’ll look at the clinical expertise and how the workflow is and the experience and what is seen.

So, we’re able to assess it from a clinical perspective. And I look at it from overall systems perspective, interoperability, security, how it works in the overall ecosystem, whether it’s a sound business decision, etc. And ideating between the two of us, we really kind of come up with a very solid solution that we’re very confident as we move ahead. But other startups, I think they have a very clear vision of what problem they are trying to solve. I know some folks say that they will do RPM primarily for diabetes management and they will be moving to a CHF type platform or COPD or other type of chronic disease states. I appreciate that honesty. They tell me what they’re really good at and where they’re going to go. I know where the baseline is from or I get a little more perplexed when people tell you they can do it all that is also known as advertising, but not in line, I think what they say is very disappointing.

And then people also underestimate the integration activities, or they don’t have good technical resources to make it easy for the health system to ingest the product and to start getting results, ultimately you want us to be your evangelists of why this product is the best thing, sliced bread. And this is the outcome of what we’ve been able to achieve by them.

PP: [00:25:01] I think that’s great advice to start ups. You mentioned that you have a clinician, a partner with whom you work very closely in determining how to roll out these programs, what programs to learn, how to roll them out and what kind of technology foundation you need to have in place and so on. Can you talk a little bit more about your governance model? What is the governance structure for driving these initiatives? Do you have a board level, C- level approval?

How do you prioritize? Can you talk a little bit about how do you fund, how do you prioritize it and implement?

RL: [00:25:46] Sure. The term digital is a very broad term. Who you talk to, it means different things. In AltaMed we do have a structured governance process that is overseen by our Executive Governance Leaders Committee of which I’m a member of. It is basically the C-suite where key decisions are made. But then when I look at, there’s really four areas that you drill down into. One part of it is the digital engagement or the patient front door, which is your website, social media and CRM patient engagement activities. Another key is going to be your clinical digital, which is tied to your EMR and the related applications and how that’s working. We try to leverage as much as we can out of Epic and the MyChart as versus looking at third party apps to have to be built on because Epic is very rich. The technical digitalization, which are many of the hardware vendors, also want to talk to you about that data center or ______

. And those are managed primarily under my direct purview. And then as we look at innovation and destructive areas, there is business strategic oversight with as I spoke earlier on, women’s health RPM and how we can leverage other types of services. So, each of these four contribute to digital. I may have left out a few other areas that are out there. But it’s a top 10 list that I review with a CEO so that I stay aligned with the CEO’s plans and what we’re supposed to be executing. The budgeting and prioritization is an art. There are lots of apps that come up and there are lots of shiny coins that are thrown out there. But again, through maintaining focus on one of those top trends and other things come up, perhaps we can put them under a sub project of one of those ______

. But as you look at something with a significant investment, we look at what is the total cost of ownership, what’s the ROI and what are the KPIs that we will be achieving. And are we going to be achieving those for a very large investment, say, over 10 million? We may bring in an outside consultant to help us get through it. So, we really understand how we’re going to be achieving those type of KPIs. But it ultimately has to make good business sense, good financial sense. And we really should not be doing it just for technology purposes. We need to have a direct business outcome to it.

PP: [00:28:25] That’s very comprehensive. We’re almost out of time here. I want to ask you just one final question here. If there’s one best practice from your experience with digital transformation and augment that you would like to share with your peers, what would that be?

RL: [00:28:42] Yeah, I would say this. I mean, I met late on my journey on this. And as I’ve been able to review your guys book, it’s really good. I mean, thank you. It lays out the steps, the technology, the approach. So, I think if you’re trying to figure out where and how to go your digital journey, if you use your book as a reference, it will be very helpful.

And the second part of that is, again, you need to have a solid understanding once the solution is implemented that you keep both a provider and a patient centric view. You cannot keep an eye view because that would ease the adoption and accelerate the overall benefits. Yeah, don’t make it an IT project, right?

PP: [00:29:27] That’s correct. All right. Thank you so much for those kind comments about the book. And I will be sure to pass this on through ahead as well.

PP: [00:29:38] Well, I guess we’re going to have to leave it there for today. It’s been such a fascinating conversation. Thank you so much for taking the time to share your experience, your insights, best practices.

PP: [00:29:50] And I look forward to following all your successes going forward.

RL: [00:29:54] Thank you. Thanks for inviting me today. I really enjoyed our time.

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