Month: June 2021

The post-COVID normal looks a lot like the pre-COVID normal, plus a plethora of other responsibilities and activities.

Season 3: Episode #91

Podcast with Mike Restuccia, SVP and CIO, Penn Medicine

"The post-COVID normal looks a lot like the pre-COVID normal, plus a plethora of other responsibilities and activities."

paddy Hosted by Paddy Padmanabhan

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In this episode, Mike Restuccia discusses the state of telehealth in the pre-and post-COVID era and how the overall workload for the technology function has expanded significantly with the onset of virtual care models. He discussed the role of the IT function in the context of the overall mission of Penn Medicine that covers education, research and care delivery.

In this extended interview, Mike discusses a broad range of topics including the role of big tech and EHR companies in the digital transformation journey, his approach to technology vendor relationships, and a governance model for identifying and nurturing innovative startups. He discusses the use of newer data sources such as genomic data in the analytics programs at Penn and the challenges of AI-enabled solutions from the vendor community that overpromise and under-deliver.

Mike also shares how he spends a significant amount of time attracting and nurturing tech talent, and how to support and empower high-performing teams. Take a listen. 

Note: Penn Medicine has published several insightful reports on the IT function’s contributions to the overall mission. These provide valuable insights into the functioning of one of the largest and most prestigious medical institutions in the country. Interested readers can download the reports here.

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Show Notes

00:48What does the post-COVID normal look like at Penn Medicine? What you are working on to prepare for the next phase?
02:52What are the broad trends in the healthcare sector and the changes in the competitive landscape that you are following at the enterprise level to drive technology priorities?
07:41 How have your patients, consumers, and caregiver community responded to the shift towards a digital mode of engagement? programs?
10:33 Have you reached an equilibrium between telehealth and in-person visits? Are you designing the future based on this equilibrium?
12:44 How do you leverage the technology partner ecosystem to drive your enterprise priorities?
15:19 When you realize that your existing partnerships might not have what you need, how do you go about sourcing it from elsewhere or you build it internally? Can you talk about your approach?
18:09 What's your advice for digital health startup founders who want to be a part of your journey and may have something?
22:28What are the challenges that you have had to overcome, especially when harnessing innovation from the marketplace as opposed to innovation from within your existing technology partnerships?
24:21Tell us a little bit about what is the overall mission when it comes to your data and analytics group. How are you supporting - the academic, the research and the health care delivery side of it?
41:10Can you share best practices for the benefit of our industry colleagues on their digital journeys at various stages?

Q: What does your post-COVID, new normal look like at Penn Medicine? What are you preparing for in the next phase, especially from a technology standpoint?

Michael: In many ways, the post-COVID normal looks like a lot like the pre-COVID normal plus a plethora of other responsibilities and activities. So, the post-COVID normal’s more frenetic with things that we’ll see much more of. Pre-COVID we’d been focused on expansion, running, maintaining and growing and all the EHR-type things. Post-COVID, it’s all that plus more engagement, faster expansion, greater monitoring of patients in our remote manor — all big lifts from an IS perspective. We had a pretty substantive role and job as a team pre-pandemic, and post it, it just doubles or triples and there’s no sign that it’s going to slow down.

Q: Interesting observation. Post-COVID, telehealth modalities and virtual care models have gained a lot of ground. What are the top three trends and how do those trends drive your technology priorities?

Michael: I will start with telehealth. Pre-pandemic, we were doing a few hundred tele-visits a month. At its peak, mid-pandemic, over 8000 tele-visits, a day. Now, it’s plateaued to around 3,000 per day, but that’s still significantly higher than our pre-pandemic days. Telehealth is here to stay. It’s an area we need to focus on and from a maturity perspective, we have a pretty good solution in place. But there are other vendors rapidly advancing their telemedicine delivery capabilities into us. Integration with our EHR is critical and getting that done in future will be top priority. Our patients and providers love it.

I had mentioned remote monitoring, a while ago, in the home or in particular within our ICUs across our six-hospitals’ enterprise. We have almost 250 ICU beds, and each is now monitored with a camera connected to a central location. Thus, tele ICU caters to 24*7 monitoring and care. It helps from the delivery of care and responsiveness perspectives and the staffing angle too, because those six hospitals are located in a 150-mile radius which makes staffing, mission-critical.

The third thing I’d speak to is just enhanced patient engagement, which can occur through the patient portal to deliver results, schedule appointments, undertake administrative types of tasks, pay bills, communicate with clinical teams or even, push information and alerts to our patients. That was significant through the pandemic. It was a new opportunity when outpatient clinics were re-opened after having ambulatory clinics, and then again significant with the re-opening of hospitals for non-essential surgeries.

We began an interactive texting campaign that communicated with patients via their phones and asked them a series of YES/NO questions 24-48 hours before they visited us. Based on the responses, the patient would either be cleared, or the employer would be cleared to come back to work. Patients could be cleared to come to the clinic or would be triaged off to a care team. The latter only if patients responded with a list of symptoms, we would not want them coming into the clinic. The care team would reach out to them at that point in time. This is another example of using technology for good engagements with patients.

Q: How have your patients and consumers responded to the shift towards digital modes of engagement? How has the caregiver community responded and what has that experience been like?

Michael: I’ll start with the patients first and this is a bit more anecdotal than scientific. What we consistently heard from the majority of the patients — and there is some differentiation based upon perhaps age or tech-savviness, irrespective — they were thankful. Thankful that we were attentive, concerned for their health and that of their caregivers and other patients in the general vicinity. Overall, it was a big win because of the positive engagement and the way we communicated with our patients.

From the caregivers’ perspectives, it was a big change in the workflow. Now one had to follow multiple steps just to see a patient. So overall, I think the response was mixed or much more positive than negative because interestingly, there was a segmentation of those physicians that were very comfortable using the technology and embraced the concept of using a telemedicine-type approach. This way, they could see more patients, have less downtime, maintain a higher adherence rate to the meeting, resulting in fewer no-shows. On the other hand, there were those that said a tele-visit was OK occasionally, but that patient had to be seen. This meant observing more than just how they were interacting through the screen.

Q: Your telehealth visits went up to about 8,000 a day from a few hundred a month. And then, fell to 3,000 a day today. Is this an equilibrium you have achieved? Are you designing the future based on this?

Michael: I think we’ve reached an equilibrium for now but there is substantial pent-up demand to come back and see in-person, which sort of impacts the decline and that plateauing. I feel there will be another bump in our use of telehealth for several reasons. One is we will have experienced that pent-up demand for in-person visits. Secondly, we’ve learned that not every visit has to be in-person and some balance/ratio of visits per patient can be maintained (one inpatient may have one in-person and two virtual visits, for example or that could be in ratio of 1:3). Thirdly, I think the strength of Penn Medicine lies in the breadth and diversity of care offered and as that expands, it will support more of the telehealth type of engagements.

Q: Penn Medicine, with its historical heritage and as an academic and research institute plus a healthcare delivery organization, is unique as is your mission. From a technology standpoint and your strategic tech partnerships, how does all this drive your mission?

Michael: We believe in few but deep partnerships. We don’t have five different vendors providing 12 different solutions for the same cause because we prefer going with one vendor across the board and implementing common systems that are centrally managed and collaboratively installed. That works very well, across the networking, EHR, telephony sides and other aspects. That’s our approach — standards and systems across the enterprise. We are focused on patient care research and teaching around 121 academic medical centers in the country. It is a unique mission that requires significant integration among those three towers than ever. Our approach towards genomics and leading that into patient care and precision medicine and precision health really makes these times exciting. And that where it gets real exciting with the things that we are doing that is transforming care. But from a partnership perspective, several solutions at most deep relationships that are common across the system is really the attributes that we seek.

Q: While your partners possibly deliver much of what you need, they don’t deliver everything. How do you go about sourcing this from elsewhere or building it internally? What is your approach like in this case?

Michael: Regardless of whether our partners are providing us the proper solution or not, we’re always looking to innovate and that’s within the corporate IS, as well as in partnership with our Center for Health Care Innovation, which is a close ally and very dependent upon corporate assets. So, the Center for Health Care Innovation is a part of Penn Medicine, led by Dr. David Asch and Roy Rosen and their team is focused on what we should be doing next to either improve efficiency, care, accelerate research. They’re quite focused on new technologies, workflows and endeavors and very dependent upon corporate IS for those networks, data, and project leadership in order to advance some of those causes.

How this works is — the Center for Health Care Innovation will identify an opportunity and organize the appropriate constituents because there’s more than IS and big thinkers that need to be in the room. One needs operational assistance, clinical assistance, perhaps research assistance as well. Once that’s organized, a proof of concept is performed to see if the thought really does hold water. If it does, then we try to do a pilot and one that’s completed, we try to determine whether corporate IS should try to scale it across the enterprise. That’s the kind of the approach we’ve taken internally to advance our causes. Often, whether it’s improving access to a particular department, making care more convenient for patients or introducing mechanisms so patients don’t have to come on-site as much and be treated more in the home, are examples of how the Center for Innovation has advanced certain causes.

Q: For digital health startup founders listening-in, how can they reach out to you or someone like you to showcase their solution or capability? Any advice to those who want to be a part of this and may have something?

Michael: People find ways to get to me, Roy Rosen, and Dr. Ashe — no challenge there. We’re pretty public figures. So, we encourage them to reach out and share their ideas and their thoughts. And we look at them all. Whether it’s patient care and engagement or access to care, all of these are things we’re readily looking at on a daily basis to try and improve upon. We’ve made a lot of advances because of the pandemic and there’s more to come. This spirit of being able to introduce things that were once thought to be not possible is amazing — Who would’ve thought you could go from 300 to 8,000 tele-visits? But when you focus on it, you can get it done.

We do have many people that reach out to us and find their way into the Penn Medicine ecosystem. It might be through a friend working here or a Board Member or via some other channel, and it just arrives. The first few times, we took a stab at trying to figure this out on the basis of the recommendations but realized that just because a person says they’re good doesn’t mean they necessarily are. We spent a lot of cycles trying to understand the firm’s stability, their product and their ability to need support, secure any data that we might share with them, their potential for long-term sustainability and had our misses.

So, we introduced a multidisciplinary committee that I Co-chair with Roy Rosen from the Center of Innovation Health Care Innovation, and we call it the New Technology Review. And before we go too far with any new potential partner, we ask them to present to the committee in a one-on-one to better understand their capabilities. This has dramatically lowered our misses, improved efficiency, communication, and efficacy as we move forward with some of these newer technologies and firms. We’ve managed to smooth the waters here and keep people focused on what’s most important.

Q: When you get new solutions, they should be compatible with your overall technology environment which can be quite a challenge. What are the top challenges you’ve overcome when harnessing innovation from the marketplace versus innovation from within your existing technology partnerships?

Michael: It’s the overselling, overpromising and then, under-delivering though some of the firms have been really solid. The sales teams or business development teams have a great vision, but on the flip side, they don’t really have the delivery mechanism tied to it. So, you end up short and that’s where my team ends up having to cover and pick up the slack, because by then, the idea has been sold and budgeted. Leaderships expects some results, after all. That to me is one of the biggest problems we’ve experienced.

Q: You’ve made great strides with your data analytics program and how you’re harnessing genomic. What is the overall mission for your data and analytics group? How are you supporting — the academic, the research and the healthcare delivery sides? What are some of the big successes or learnings you’ve had?

Michael: I’m not the greatest one with vision, but my team is using that construct of a common system — centrally managed and collaboratively installed. If you keep that as the overriding umbrella, then, the spirit around analytics was that we needed a centralized location where we could house patient care data, research data — biobanking, bio tissue, genomic data, and any other types of demographic data. That’s Penn GNP (Penn Genomics and Phenotype). That data is initially loaded in a raw format, so, if someone wants to reach in and grab raw data, they can if they’re savvy enough to do that.

We then move up a tier and we synthesize that raw data and homogenize it into common data definitions – a common data model accessible with common tools and probably a little easier then, for an end-user to reach in and grab what they want at some point. But again, it’s a common location that we’re zeroed-in on.

Finally, what we will do is move that data off into data mart so we might have patient safety and a quality mart. We might have a clinical care art. We might have a research mark that has just that specific domain data associated with it. We do all this now through the Azure Cloud, which we found again makes access to the data even easier through the utilization of standard tools that are accessible to all.

Our goal is to have our end users be less reliant on our data access team and more reliant on themselves through self-service. That may be a big lift for us as it is for many other organizations. How we communicate and educate that end user community and liberate the data for their use so that they’re not as dependent upon us is critical.

Some of the big successes for us are — we were one of the first, if not the first, to begin to take discrete genomic lab results from one of our lab partners and integrate that into our EHR. We put a whole program in place on how to make that work, utilizing our genomics team, genomics counselors, members of our cancer center and then, certainly our end user clinical staff community. We ensured that when these Genomic results showed up in a patient’s chart, the latter was aware of what they had, their result and the implications to the caregiver because many of them could require some level of training and education on how to discern what that variant result might be.

Q: AI means a lot of things to a lot of people. How have you been able to leverage AI, ML, Analytics tools in the context of your data and analytics programs?

Michael: AI falls right under that banner of over-promising and under-delivering and I don’t think I’m the only one to say that. You’re more connected in the industry than I am, Paddy, but I have hope for it because much like innovation was a four-letter word a bunch of years ago, AI is becoming a four letter word since it’s just overpromised at this point with limited, tangible results.

That doesn’t mean that we’re not making strides towards it being more and more beneficial. We are taking a two-pronged approach towards AI. The first is a top-down approach, where we will work with members of the vendor community who claim to have this algorithm whereby if you give it the right data in the right format at the right time and in the right sequence, it’ll tell you something. It might tell you whether — you’re going to have a higher no-show rate, there’s going to be a health deterioration, Sepsis is on the horizon etc. And that’s our top-down approach, where globally we’ll just lay it over the enterprise. We’ve had minimal success with that so far.

We also have a bottom-up approach. I have a team of seven or eight data scientists that work in a more discreet manner with our end user community and some passionate clinicians or researchers who claim they have this great idea. And if only they’ve observed certain things or had data on those things, it could be combined again. In some way, we could develop an in-house algorithm that would bring great benefit to the group. And I think we’ve seen that particularly in at-home care. We see that in palliative care, where we’ve predicted certain occurrences, but that’s in a very narrow tower. It’s not as broad as my top-down approach. So, we will continue on both streams because we think there’s hope. We are big believers, that the answers are in the data or are often in the data and we just have to get better at figuring out how to combine that data in order to generate a proper result.

Q: That’s a very well-balanced articulation of the promise, the potential and the actual performance of AI, today. And like you, I’m optimistic about the future as well. I know you spend a lot of time on your people. How do you ensure that you’re attracting, retaining and nurturing talent within the organization? All this technology is only as good as the people who are committed to making it all work.

Michael: When I joined Penn Medicine 14 years ago, 95% of our IS services were outsourced to third-party vendors. That was done 20 plus years ago for a variety of reasons — cost containment, standardization of delivery capabilities etc. What I was asked to do was help build a team that would in-source the majority of those services, because if you’re going to have world-class clinicians, researchers and educators, you better have world class IS.

In order to enable it — and you’re generally not going to get that passion and commitment from a third party — my job was to rebuild the team, internally. That took about three or four years to in-source, and during that time it gave me and my team, the opportunity to build a culture that was accountable, exceeded expectations, and in which we were viewed as consultative and partners versus just “those folks in IS.”

Building that culture has really put us in a position where we’re attractive to those that we recruit. We want 100% of the people to be doing 200% of the work and be accountable. Our mantra outside of corporate IS is, we always deliver. And it’s not easy to do that and so people do go above and beyond and exceed those expectations. That was a culture we strove to build.

I’ve had the good fortune of working places prior in my career where I saw that culture. I thrived there and wanted to replicate that. Now, we are a USD 280 Mn IS operations business, here. And a big business cannot function properly without really good people. My teammates are great, our leadership’s exceptional.

One of the things that caught me — and I probably haven’t shared this with you before or my team — is despite the fact where you are in Penn Medicine, part of University of Penn trustees, we really didn’t have an internal Managerial Training Program. And if you look at statistics and surveys, one of the top reasons why people come to work every day for that employer is they like working for their manager, they respect their manager, they believe their manager has their best intentions for them with their career and their personal work-life balance.

Well, Penn Medicine has subsequently introduced the Managerial Training Program, but IS did this first, and on our own. We formed a program, educated our managers on how to be not only good technically, but good personally, in their management styles. That to me was one of the best things we’ve done within our organization.

I have over 100 managers and often in a technology world the people that become managers are the best subject matter experts in their technology. Well, I think we all know just because you’re a really good C++ programmer or a really good infrastructure networking person doesn’t mean you’re a good people manager. And we had to bridge that gap and we’ve done that through a series of internal trainings, hosting webinars, team meetings, book readings, book discussions and team discussions, and it’s really elevated our ability to manage. Each of my team has now been through 360 events, twice. So, they’re receiving feedback from all around them — their employees, leaders, colleagues etc. If you invest in people, they’ll respect you, like the culture and in the end, this will account for a really low turnover and really high retention rates.

Q: You also published a biannual and having read the document, I’ve found it to be very informative. For those who are listening to this podcast and watching this, I strongly encourage downloading the documents and learning a little bit about what and how medicine does it.

Michael: I’m happy to share that link with you. Our Benefits Realization is one document that states the financial impact corporate IS has on many of the larger projects. And we do that every two years. In between those two years, we do the State of the Union, which highlights the big projects that we were working on, a little less on benefits, but more on the function of that particular project. And we do that because marketing our services is important so the external community understands our end users, what we’re working on, where that USD 280 million is going to. It’s also really rewarding and refreshing to the employees to see their efforts in print and recognize that. “I worked on that with that department or that center or that entity,” has a ring of a sense of pride, a sense of ownership and a lot of what Penn Medicine is about, is that pride and ownership.

Q: I’d like to conclude this session with one or two best practices or learnings and especially in the context of this transformation that the industry is going through. What would you like our listeners to take away from your experience?

Michael: First, we have to recognize the unique situation we are all in — any individual can make a big impact in some way, shape or form. Within industry or within personal and social lives, anyone can make a big difference. I happen to sit in the seat of the C.I.O. so, I have a bit more influence than most. What I have found is, you need to be bold, selective and pick your shots and go hard at them.

When I joined, one of the goals was to in-source the services, but that wasn’t so bold. It was more something that I needed to do type of thing. I thought some of the boldness way back then was saying we needed to get to an integrated health milestone.

Back then, everybody had their own little pet product or pet solution for filling in. Each ambulatory department had their own car — Orthopaedics or GI — and nothing was connected. The boldness was to get to one and being able to fight off all the reasons that people would give you for not getting to one and continually representing what the benefits could be. Once the approvals were got, then still having energy left and implementing that type of a solution today may not seem like a bold premise. But back then, it certainly was. And it makes a big difference today.

I think when I look at what is there and what’s going to be more of, I come up with more genomics, more data, more engagement – the whole precision medicine. The approach we’re focused on has led us to restructure the corporate team, so we’re focused on maintaining power and doing things on the research side. Now, we have a team focused on bringing those two together, and that’s bold and unique. But as mentioned, Penn Medicine is a pretty unique place.

So, we need to take this to the next level and leverage that position without forgetting all day-to-day activities that have to still take place.

About our guest

Restuccia_2021-profile-pic

Michael Restuccia is the Senior Vice President and Chief Information Officer (CIO) at Penn Medicine. Restuccia has over thirty years of healthcare information technology experience and has worked nearly all his career in the healthcare information technology provider, vendor and consulting services industries.

Prior to joining Penn Medicine as an IS management consultant in 2006, Mr. Restuccia served as President of MedMatica Consulting Associates, a healthcare information technology consulting firm that has been recognized as a four-time recipient of the Inc. Magazine 5,000 Fastest Growing, Privately Held Companies in the US and the Philadelphia region.

While at MedMatica, Restuccia served as the Interim Chief Information Officer for several healthcare organizations, including Phoenixville Hospital, Doylestown Hospital and the University of Pennsylvania Health System. Prior to MedMatica, Restuccia served in leadership roles with several other healthcare information technology firms, including First Consulting Group and Shared Medical Systems (now Cerner Corp.). Restuccia achieved a Bachelor of Science degree from Rider University and earned a MBA from Villanova University.

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.

Our challenge now is using the data correctly to generate actionable evidence and insights

Season 3: Episode #90

Podcast with Dr. David McSwain, Chief Medical Information Officer, The Medical University of South Carolina

"Our challenge now is using the data correctly to generate actionable evidence and insights"

paddy Hosted by Paddy Padmanabhan

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In this episode, Dr. David McSwain, Chief Medical Information Officer at The Medical University of South Carolina discusses the lessons learned in integrating technology into clinical care and its impact on the workflow of physicians, care team members, and patients. He also shares best practices in telehealth implementation from a clinical and operational standpoint. 

David talks about the disparities in access to care among populations with socioeconomic disadvantages and the challenges in implementing telehealth programs. MUSC’s Sprout program, the nation’s first national collaborative telehealth research program, uses evidence and data to support and provide quality healthcare services and influence the adoption of telehealth technology at the physician level.

While designing and implementing technologies, David advises a consumer-focused approach for an improved experience for both providers and patients. Take a listen.

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Show Notes

01:23Can you tell us about the Medical University of South Carolina and the populations you serve?
02:37Did you manage to codify some of this knowledge, learnings, and best practices so that your peers across the country could utilize it?
05:10 The application of telehealth programs and technologies can vary widely. Can you help us parse through it for someone who is relatively new to implementing telehealth programs?
08:34 Can you talk about one of the challenges that you've faced in rolling out a telehealth program?
10:22 Can you talk to us about pediatric research - the Sprout program?
15:24 Are you seeing telehealth platform providers step up to the challenge and introduce the capability to have a translator in the mix every time there is a video conference call?
17:18 Are you harnessing the data that is coming out of the emerging technology platforms like NLP, conversational AI, voice recognition, etc., to improve outcomes of productivity and improve the quality of the experience?
20:03What are some of the biggest challenges when you're going beyond your core electronic health system and trying to tap into some of the digital health innovation or innovative new technology solutions that are out there?
23:46Can you share your thoughts on how providers can improve the way they deliver care and be more productive and not burnout in the process?

Q: Tell us a bit about the MUSC, the population you serve, and your role and responsibilities there. What kinds of programs do you run?

David: The MUSC is an academic medical center in Charleston, South Carolina. We have five campuses throughout South Carolina and serve the entire state. In addition, there are six different colleges, a diverse student body across health professions and disciplines, as well as great research infrastructure. These have contributed to and driven innovation. As the CMIO at the MUSC, I look at the integration of technology especially in clinical care — and how that impacts the workflow of physicians and other care team members — and patient experience and focus on such integration across different types of technology to streamline the practice of care.

Q: How did you codify some of this knowledge, learning and best practices into something that your peers across the country could utilize?

David: Our Centers for Excellence have produced a number of instructional documents and resources on how to implement telehealth best practices, both, from clinical and operational standpoints. We’ve done a lot of work in the spaces of education and training. In fact, several years ago, we opened a state-of-the-art Center, the Telehealth Learning Commons in our main campus through which we’ve hosted different clinicians, administrators, operational personnel and policy makers from across the country to demonstrate the value of telehealth. That space is also used to conduct classes. But all this was largely pre-pandemic, of course. We have, however, expanded on how we approach interdisciplinary education in terms of developing competencies for telehealth across different disciplines and preparing our workforce of the future to be engaged in telehealth as they go out into their chosen professions.

Q: If one of your peers across the country wants to access some of these materials or programs, where should they go?

David: Our website for the Center for Excellence at MUSC.edu is a good resource and to access profiles, there are Twitter and LinkedIn as well.

Q: The meaning of “telehealth” varies — depending on who one talks to, and may be based on demographic profiles, geographies and the type of care being delivered – as widely as the application of telehealth programs and technologies. Can you help us understand telehealth and how best to implement these programs?

David: Well, the key really is to focus on the problem one’s trying to solve rather than the technology. There’s a variety of technology available and the emerging technologies advance what we’re capable of. So, you don’t want to walk around with your hammer looking for a nail. You want to really focus in on the requirements and the gaps. Once you define what it is that you need to do — how to improve patient care, enhance workflow of your providers, coordinate care across settings or across institutions and across locations – and identify the challenges to be addressed, then, the tools will present themselves. These may span a synchronous video consultation, physician-to-physician, physician-to-patient, an asynchronous encounter, remote patient monitoring — there’re so many different tools that it can be a little overwhelming. But the best way to focus in on that approach is to start with that problem.

Q: With regard to synchronous video conferencing or even a phone call and a number of other things, isn’t telehealth just that?

David: That’s actually a really key point, especially now in the pandemic. As we emerge from it, and it gets to the issue of health — of equity and disparities in access to care — some of the research we’ve been doing actually demonstrates that those at a socioeconomic disadvantage, or with pre-existing disparities in access to care, use telehealth as a broad term at the same rate, or that utilization has increased similarly, across those groups. If we look at the distribution of whether it’s video telehealth or audio telehealth, those who are coming from disadvantaged backgrounds or from other areas that don’t have the same access to technology, seem to be disproportionately using audio telehealth. And that’s really important because as we emerge from the pandemic, looking at the ongoing policy debates and the regulations enacted during the public health emergency as they begin to expire or be rolled back, if the reimbursement for audio-only telehealth is peeled back more so than reimbursement for video telehealth, suddenly we’re only actually exacerbating the disparities. And that’s something that must be maintained and focused on.

Q: What are some of the challenges you’ve faced in rolling out a telehealth program?

David: One of the big challenges is access to broadband and it’s been very apparent during the pandemic. Broadband is something many of us take for granted but in rural areas, people may not have access to it. Another important consideration is when you have access to Broadband, whether you can afford to pay for the data that it takes to do a telemedicine consult. Those may be two completely different things. And so, you need to take that into account as you’re rolling these programs out. The other really important lesson learned is to focus on usability both, for the patients and the providers. The first telemedicine program that I developed was a pediatric critical care telemedicine program that provided emergent consultation to rural community emergency departments for critically ill and injured kids that came into those facilities. In such situations, it’s incredibly important for the system to be as easy to use as possible in that rural or community emergency department, because often they’ll have a very chaotic or very least-very high stress situation, on and logging into your system shouldn’t be worrying. You want to just roll the cart into the room and make that connection. That’s how we develop that program and it was one of the really key aspects of that program’s success.

Q: You’ve been involved in some very interesting work on pediatric research — the SPROUT Program. Please elaborate on this.

David: SPROUT is really the nation’s first national collaborative telehealth research program across both, adult or pediatric services. The SPROUT Network was formed because of the recognition that advancing quality telehealth services really requires having the evidence and data to support what it means to provide quality health services. If you really want to influence adoption of telehealth at the physician level, physicians have always been raised on the concept of evidence-based medicine. If that evidence’s missing, it doesn’t matter that the telehealth program sounds like a terrific idea. They need to know that when they’re going to be taking care of their patient, when it’s a change in practice to the way they interact with their patient, that the evidence is there to support it. SPROUT, stands for Supporting Pediatric Research on Outcomes and Utilization of Telehealth, was formed with several very talented folk from across the country who came together and developed the first National Pediatric Telehealth Infrastructure Survey. We collected data from across the country and developed a collaborative of over 140 institutions across the country and in some other countries that develop frameworks and best practices and provide education around how to study telehealth in your particular institution. We got NIH funding back in 2019 for the program through the National Center for Advancing Translational Science. And we’re just getting into the third year of that funding. Obviously as we went into the pandemic, all of our work became critical to the way that telehealth was being practiced, especially in pediatrics nation-wide.

Q: Given the program is now 2 years old with ample data, could you share one or two findings that may be worthy of consideration?

David: One of the things we did very early on during the pandemic was we brought together national webinars to explore how people were utilizing telehealth in the pediatric setting and studied the challenges they experienced. We identified very early on, the challenge for non-English speaking populations in terms of access to telehealth. Now, the majority of telehealth platforms have been designed with the assumption the patients speak English and that bringing in a translator into a telehealth interaction can be difficult. The platforms themselves often are not available in anything other than English. And that was something, as telehealth programs scaled out across the country very rapidly during the early days of the pandemic, that a lot of institutions were really not prepared to address. Thus, SPROUT served as a convener to bring people together and identify best practices to how to approach that and serve as broad a population as possible. We’ve also done a lot of evaluation around how different institutions and different practices have responded to the pandemic and are working on getting published some data on educational approaches to scaling out telehealth services. We’re also working on publishing a policy evaluation stakeholder table or framework that allows one to evaluate programs based on the different stakeholders that may be engaged in moving a program forward. That may be a hospital system, a patient, a provider or even, a policy maker. We really have a very broad array of tools that we’re developing and they’re really coming out.

Q: Telehealth and the pediatric context is a very interesting space because it’s not just about the minor patient but about the parent, too. Sometimes, both entities may be in different locations and there’s the translator in the middle which can be confusing. But doesn’t this also apply to adult care? Will telehealth platform providers introduce the capability to have a translator in the mix every time there is a video conference call?

David: A lot of people in the industry and vendors have been focusing on this in the last year. Some really creative approaches have now been rolled out. Obviously, multi-party calling is a big part of that — just being able to bring an interpreter into the virtual room when needed, ensuring that the platforms themselves, the education provided there and the instructions are multilingual. Some of the really exciting stuff though involves technologies such as, natural language processing, real-time interpretation and the use of voice recognition — the kind of tools that, when we look back 10 years from now, will reveal how the pandemic really shifted the evolution of telehealth and digitally-enabled health care, in general. The integration of these emerging and promising new technologies into a unified approach addressing those with chronic disease and some of the most challenging patient populations around is possibly where the shift really happened this past year.

Q: Natural language processing, voice recognition, chatbots, Google Glass enabled services – are all based on natural language interfaces. As the CMIO, how do you view the data from these platforms and interactions? How do you harness data streams to generate insights that can improve outcomes of productivity and the quality of the experience?

David: This is one of the key issues that needs focus once we come out of the pandemic especially if we’re to stay focused on the telehealth aspect of things. There’s been such an explosion and adoption of telehealth that our previous challenges around not having enough data is really a thing of the past. Our challenge now is to use the data correctly to generate actionable evidence and insight into what is the best practice. How do you coordinate this across different practices and technologies? How do you develop that hybrid approach to providing either in-person or virtual care by a number of different modalities and do so in a way that is streamlined, that fits into the workflow of clinicians and other providers, and that supports the operations of the hospital in an effective way? Looking at this massive trove of data we have now, one of the things that SPROUT has done is develop a telehealth evaluation and measurement framework that helps folk make sense of all the data coming in. Look at it from the standpoint of a particular program, at a particular stage of maturity, from a particular stakeholder’s viewpoint and the population that’s being served. How do you pull the most meaningful data in the most generalizable information out of the data you’re getting for this service to really advance that safe and effective telehealth service going forward?

Q: What are some of the biggest challenges when you’re going beyond your core electronic health system and trying to tap into innovative new technology solutions? How do you address the integration of different platforms with the main electronic system and more importantly, ensure cybersecurity?

David: People get tired of the term governance, but that’s what’s incredibly important and really generating the alignment. These different technologies often emerge and become central to everything we do in the health care system. Consequently, it’s hard to identify a technology that only impacts one area. There will be overlaps and duplicative capabilities of different platforms. So, there will be platforms that are already in place to do the things for which people are looking at newer platforms. Then it’s important to understand — what your current capabilities are, what is the real gap in what you can do, and how the technology that you have could address those gaps versus what new technology you may need to invest in to be able to effectively address those gaps. That’s a real challenge because, in a health care system — particularly an academic system that has research, education and clinical components — there is a revenue cycle and operational issues and these platforms can be highly integrated. They also cross over into so many different areas that it’s hard to have a good understanding of how your platform and technology decisions impact all the different areas of the institution. Gaining that alignment and that shared decision-making and having that governance in place, is incredibly important.

Coming to the second question, a few months ago, I would have said cybersecurity is an under-recognized risk. But today, I feel like it’s not really recognized anymore. While we have major health care systems now that are being forced back to paper for weeks at a time because of prohibitive ransomware attacks, you have to invest proactively in your cybersecurity. While doing this, you also have to be very proactive in how you engage your cybersecurity team to ensure that they can identify where the risks actually lie. We’re long past the days when a platform could be evaluated based on a clinical need and then handed to the security team to ensure proper fit. The security team must be engaged early on in the process to ensure that you’re not exposing risks that you may not have even recognized were there.

Q: We’re coming to the end of our program now. But there’s one aspect yet to be touched upon. How does one ensure that providers and caregivers can enhance the delivery of care, stay productive and not burnout with the new technologies?

David: I think it’s incredibly important and we all know by now that provider burnout is real. The emergence of technology had and still retains promise, but the ways in which it has, at times, been implemented, has exacerbated challenges and increased workloads on our providers. Organizations like the ONC have taken steps to streamline the electronic health records and there’s some progress there. But increased focus in the health care industry, currently, is on consumerism. There’s certainly a lot of value in that. While there may be some patients that we shouldn’t really think of as consumers because they don’t have those consumer-type choices when they have the significant chronic or complex diseases, still, I see the value in the consumer-focused approach. However, one thing often overlooked when discussing digital health and technology, is that the providers are consumers, too. When it’s a new technology being adopted, especially one that sits in the interface between the doctor and the patient or the nurse and the patient, then there are two sides to that interaction and both are the consumer. When one’s designing, implementing technology or training and supporting it, one must think of the providers, physicians, one’s care team members as one’s customers, because really that’s how they function. If that mindset can be developed around both sides of the equation, then, one can really make a lot of progress in making the experience better for everyone.

About our guest

Dr. Dave McSwain is a Pediatric Intensivist and the Chief Medical Information Officer for MUSC Health in Charleston South Carolina. With over a decade of experience in digital health innovation, clinical informatics, and virtual care, he is an established national leader in telehealth development, research, and policy.

He is the Main Principal Investigator for the NIH/NCATS-funded SPROUT-CTSA National Telehealth Research Collaborative and the Chair of the Section on Telehealth Care at the American Academy of Pediatrics.

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.

In the future, we will see smart adoption of Google Glass technology in clinical use cases.

Season 3: Episode #89

Podcast with Ian Shakil, Co-founder, Augmedix

"In the future, we will see smart adoption of Google Glass technology in clinical use cases."

paddy Hosted by Paddy Padmanabhan

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In this episode, Ian Shakil discusses how Augmedix became the first company to launch a clinical application using Google Glass and a phone to convert the natural clinician-patient conversation into medical documentation.

There has been an increase in adoption for natural language interface technologies for clinical applications in healthcare involving hardware, software, and data analytics. Augmedix works as a tech-enabled remote scribe that processes conversations and distills it real-time into a structured note in the electronic medical record.

Ian also discusses the differences between Google Glass and other conversational interfaces such as voice recognition technology, and how conversational AI tools are evolving in healthcare, specifically in clinical use. Take a listen.

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Show Notes

01:12About Augmedix and the journey about launching the company.
06:08What are the differences between a voice recognition tool like Alexa, Nuance, Siri and what an Augmedix type service does where the hardware is a little different?
11:05 How your technology space is evolving in the context of clinical applications in the healthcare space?
13:49 In the clinical context, what is holding back the growth of these kinds of conversational interfaces?
16:32 How do you see your competitive landscape? Who do you think you're competing against?
18:55 What is the reimbursement environment look like? How do you build a case for a solution like yours?
21:01 What do you see as a big trends emerging as it relates to the moves that big tech firms are making in the market?
26:17What is your advice to digital entrepreneurs and VCs who are getting into this space?

Q: Tell us a bit about Augmedix and your journey.

Ian: I’ve always been excited about healthcare, technology, wearables, and the Internet of Things. So, around 2012, I’d just graduated from Stanford and was meeting some friends from Google. They shared news about some secret hardware they were developing — the Google Glass. In 2012, no one had ever heard of or knew about Google Glass. They let me try this secret hardware but under caution. When asked, “What do you think about this glass prototype hardware?” I said, “Have you thought about doctors? Here’s what you could do in the world of healthcare.” And that was the background.

I got laughed at because they were thinking about consumer applications more like “Dads in the park go pro at selfies” but I stuck to my theory — doctors and enterprise. We agreed to disagree, but I got obsessed enough to find the very first glass company of any sort and create an application for healthcare; for doctors, specifically. With Augmedix, we endeavored to really rehumanize the doctor-patient interaction using technology, such as, Google Glass. Today though, our service has evolved, and we now use many different hardware above and beyond Google Glass.

If you visit a doctor now, it’s a pretty miserable experience as they are typically typing, charting on the computer rather than paying you attention. So, crucial hours of the day are wasted in updating electronic medical record. Fundamentally, we solve that problem. Our doctors put on technology, have phones in the room or use Google Glassand from there on, we are virtually present. Augmedix takes natural doctor-patient conversation and produce EMR notes better and faster than what the doctors would do on their own. In essence, what Augmedix does is, it enables doctors to focus on what matters most — patient care for the patient right in front of them.

Q: Is it that the technology is automatically transcribing the conversation?

Ian: It’s true. But there are a lot of details beyond that. Most of our doctors use smartphone kits, Glass, and the phone. We transmit the visit, the audio and the video to our platform. So, a tech-enabled remote scribe processes the conversation and distills that into a structured note for the EMR. Unfortunately, natural language processing in AI hasn’t reached the stage where an ambient conversation can be processed and results in a perfect note without human involvement. We’re unabashedly human but we skip the chit-chat and focus on what’s medically pertinent and constructive in that conversation to create a note in the EMR — Epic or Cerner – used by the doctor.

This tech-enabled remote scribe at the backend operates within what we call a Scribe Cockpit. It’s a bunch of specialized automation modules that de-burden the Scribe. So, when the note is being constructed, a few clicks and edits happen in our natural language processing Note Builder. This is described as invoking a SR or Speech Recognition modules to create parts of the note in the scrabble and edit those attempts. A marriage of human involvement and technology make a service like Augmedix possible. Yank the humans out of the loop and try to do something with only software, then, it’ll only be something like dictation with the doctor being verbatim throughout the note. That’s been around for a while and isn’t helpful at all.

Q: What’s the difference between what a voice recognition tool like Alexa, Nuance, or Siri and what an Augmedix type service does where the hardware is a little different?

Ian: I’ll segment-out the market and help you understand this. Voice Recognition or Speech Track or Dictation is a whole category that’s been around. A dominant player there, is Dragon. The key marker here is the doctors are basically being verbatim — pressing a button, taking their device and noting their patient presented with this and that.

There’s another category of solutions — in-person, on-site scribes – very like having a third person in the room following you around, computers up, typing, charting, clicking, observing the conversation as it unfolds. There’s no time wasted having to structure, dictate, and review those dictations in this case. The downside is that it’s not scalable – these persons take up physical space, they call in sick and there’s all kinds of quality issues.

We’re in a new category of being remote. We offer all the benefits of that in-person scribing experience but are more cost effective and scalable. We also layer-in technology in ways that were previously impossible. So, like Dragon in-person scribes, and now we’ve got remote scribing or ambient remote documentation.

Q: You were the first company to launch a clinical application for Google Glass and its adoption in the clinical context is still coming along. As a dominant player, what does the rest of the market look like? How far as a technology is this and where is it headed from a broad-based adoption standpoint?

Ian: Google Glass, when it originally launched, was all about consumers. But they ultimately pivoted their glass efforts and refocused them on enterprise applications, of which we are one and certainly the dominant player in healthcare. But within the glass space, there are other very interesting applications and enterprise oil and gas field manufacturing, all kinds of fulfillment, applications of glass and things like glass. It’s a vibrant space but still early. We’re on third-generation hardware now, which is better today than it was 7-8 years ago and the devices last longer, plus Wi-Fi is a lot better. There are more robust enterprise-grade security configurations and settings now so further evolution is expected and smart glass adoption in all of those categories may just be on the rise.

Q: Augmedix went public recently through a somewhat unusual process. Can you brief us on how that looks like?

Ian: Augmedix is now a publicly tradable company under the ticker AUGX. We are listed on the OTC and we are public by way of a reverse merger. It’s a really exciting opportunity for us. For one, we raised additional funding through this process, which fueled our ongoing growth, investment and commercial expansion, investment and technology. We see incredible enthusiasm in the market among all sorts of investors to participate in something like this, which really is a play on burnout, digital health, and telehealth. And so, by being public, we’re able to take in the full spectrum of interested parties and investors that want to participate in Augmedix and prepare for more growth ahead.

Q: While the technology and the clinical applications involve special hardware, software, data analytics, let’s talk about Voice, Chatbots and Glass. How is this space evolving in the context of clinical applications in the healthcare domain?

Ian: Conversational AI is creeping in, in so many interesting ways in healthcare especially with activity such as, patient engagement and interaction. There are many opportunities for patients to be reminded of activities and care goals in remote, asynchronous and conversational ways. Many companies are doing this over text, asynchronous text, SMS platforms. But that’s different from what we’re doing though.

I think our area is white-hot since it’s looking at doctor-patient conversations and deriving structured EMR outputs using technology. We’re the pioneers and the biggest and now, in two key areas. Now, there are other areas where, if you think about it, patients do engage with smart speakers at their bedsides but that’s another aspect of conversational AI and innovation. I’m also seeing applications for communicating with staff, sharing information with family members etc. and there’s a lot of activity there, too.

Q: Patient engagement is critical amidst all the technological advancements. How does your technology handle and manage the patient/consumer side of the conversation in the clinical context? What could be the hurdles here?

Ian: Patient resistance or negative patient reaction was a concern when we first launched Augmedix. But patients are widely accepting the use of Augmedix on phone or on glass in their clinical interactions with their doctors. We always ask the patients if they’re comfortable and ok with the use of Augmedix at the point of care that typically happens on the first visit by the front desk or by the MA. We measure the decline or off rate and 98% of the time, patients are OK and accepting the use of Augmedix in that environment. Patients irrespective of their genders, geographies they come from, age, etc., prefer this new mode of interaction with their doctors.

We also provide the patient with all sorts of assurances around security and privacy. If there is a moment of nudity or anxiety, we go on to incognito mode.

We can juxtapose that with other conversational AI systems, like patients engaging with a chatbot but the difference lies in the marked absence of human insight. Is the human reviewing or involved in high impact decision making? Then there are texts coming from a system that may have a picture of a doctor by that or not. But you’re not verifying with your own two eyes that the humans in the loop qualify. I would expect that the level of skepticism and adoption in that system is higher than the level of skepticism in our system. So, I would advise those companies to do everything they can to indicate and highlight the level of human review early especially for high-impact decisions to kind of tackle that skepticism.

Q: What about your competitive landscape?

Ian: The market is enormous and the vast majority of doctors we encounter are using no solution. They’re toiling away in the EMR looking for a way out. This space is getting a lot more attention with many new entrants. I call them – ‘fast followers.’

A big new entrant here, for example, is Nuance with their DAX product. It’s distinct from their Dictation Dragon product. There are others too, but we are distinct from Nuance. One of the ways is we operate in real-time; we are a live service. Our notes and our interactions are being created literally in real-time as conversations progress, so, that benefits productivity and alleviates memory burdens for doctors.

Another benefit associated with being real time is that we can be interactive and offer you additional services — fire off strategic orders and referrals, remind you regarding HCC and other items etc. All this is possible because of our live and interactive presence.

We also offer a non-real time asynchronous service in that category, with advantages – it’s flexible and affordable.

Q: What is the reimbursement environment look like? How do you build a case for a solution like yours?

Ian: We save doctors a lot of time — two or three hours a day and sometimes more. Doctors can use these savings to see more patients per day. If you’re in primary care, it may take one or two more patients a day to forthrightly pay for the service. If you’re a specialist, the hurdle is even less than that. And if you are being saved two or three hours a day, that’s not so much of a huge ask frequently.

In addition, we see that more revenue per charge is generated when documentation is thorough and accurate, as is the case with us, which is another ROI proposition for us.

Another key thing to mention is we alleviate burnout which is a serious issue. There’s a scarcity of doctors in America right now. Doctors are partially quitting and are leaving health systems. Whenever a doctor leaves the health system or doctor group, it’s very costly, huge productivity loss, plus it’s difficult to find a new doctor and ensure productivity resumption. It could cost nearly a million dollars when a doctor leaves a health system. There’s evidence that Augmedix really rekindles doctors’ love for the practice of medicine, staves off burnout and that’s why a health system would adopt Augmedix.

Q: You mentioned Nuance’s Dragon technology was about to get acquired by Microsoft. What are the big trends emerging related to the moves that big tech firms are making in the market?

Ian: It’s big news that Microsoft and Nuance are now one. As to the thesis behind that marriage, I would argue it’s a little bit of a Rolodex play. We see that Nuance through its legacy products, such as, Dragon is present amongst the majority of health systems and doctor groups. So, one reason for Microsoft’s interest could be so they can upscale into those health systems and doctor groups where there’s just so much market share and access through this acquisition and upscale Azure and Azure-Related Tools and other Microsoft related tools.

Microsoft is also excited about this ambient documentation space and other things that Nuance DAX is doing. Other big tech companies are equally excited and waiting to jump into healthcare because it is such a huge percentage of the U.S. economy. A lot of these tech companies are creating tools and modules that are going to be very useful to Augmedix, such as specialized, medically tuned speech recognition modules, natural language processing modules, cloud hosting and compute capabilities tuned to healthcare needs with the right types of security and compliance aspects. And they’re getting competitive and innovative. But they are stepping back from providing the end-to-end, go-to market and product solutions in those areas. I saw more attempts toward this earlier so that is kind of a trend I’m seeing among these big tech companies.

Q: The one exception to that may possibly be Amazon, which is actually getting into the healthcare services space with AmazonCare. Where do you see yourself in the context of this big tech firm? Do you see partnering with one of these big tech firms in making your technology available?

Ian: Yes. Tech companies are creating more enabling modules versus end-to-end products but this is more around my domain, specifically. In other healthcare domains though, Amazon is jumping into the fray. Over the years, we’ve had significant partnerships with more than one of the big brands, tech companies and we have diverse partnership projects and collaborations with many of them. We use many different enabling tools, cloud systems and hardware — while we don’t make Google Glass, we rely upon Google for their production. So, there will definitely be opportunities for us to get strategically comfortable and focused with just one of those tech companies but presently, that’s not what we’re doing.

Q: You’re one of the first companies launched in the digital health ecosystem. You’ve seen companies come and go, pivot, fail. There’s enough capital floating around and ideas. What is your advice to a digital entrepreneur who is getting into this space now and what is your advice to the VCs?

Ian: Certainly, this space is a lot busier now than it was in 2012. Most of the areas of great pain and need now have a few different venture-backed startups chewing away at the problem, taking different approaches. While that shouldn’t scare anyone away, it creates a situation where most of the digital health innovation is maybe in the mid or later stages and not so much in the very early founding seed stages. There still is an opportunity to found seed-stage digital health companies. The burden of proof is going up now versus previously fair not to get funding and to get initial traction. So, my advice is that the ROI and the validating metrics required for you to get attention and funding and the expectations there, have increased greatly. This isn’t the time to step in with incremental solutions and sort of iterate your way to path forward. It’s time to meet unmet needs with eye-popping ROI benefits that happen pretty quickly. Otherwise, you’ll be passed over in this extremely noisy space.

Entrepreneurs must really focus on clever go to market strategies to scale faster and be data-driven and metrics oriented so that you can prove to all the stakeholders that you’re adding a lot of value. Early-stage entrepreneurs need to invest in the analytics and ROI on day one and overly so to stand out. That’s necessary in today’s environment.

About our guest

IanShakthi-profile-pic

Augmedix Founder, Ian Shakil (pronounced like Shaquille, the basketball player) has an impressive track record of innovation in cutting edge domains such as wearables, smartglasses, global-scale digital health, and IA (intelligence amplification).

In 2012, he founded Augmedix with a mission to harness technology to improve the patient experience and allow doctors to focus on what matters most: patient care.

Shakil holds a BSE in Biomedical Engineering from Duke University and an MBA from Stanford Graduate School of Business.

Before founding Augmedix in 2012, Shakil held a variety of roles at leading healthcare companies such as Edwards Lifesciences (where he still consults), MC10, Intuitive Surgical, and HealthTech Capital. He currently resides in San Francisco.

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.

Technology in healthcare needs a purpose-built solution to solve the problems

Season 3: Episode #88

Podcast with Murray Brozinsky, CEO, Conversa Health

"Technology in healthcare needs a purpose-built solution to solve the problems"

paddy Hosted by Paddy Padmanabhan

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In this episode, Murray Brozinsky, CEO of Conversa Health discusses how conversational AI can complement care delivery models and the need for AI and clinicians to work together to apply these tools to clinical use cases. Conversa’s virtual care and triage platform leverages a 360 view of the patient in real-time to predict clinical pathways and make recommendations.

Murray also talks about the virtual care automation programs that are being integrated to manage chronic care, post-acute care, perioperative to women’s health, cancer, pediatrics, and in the ED. AI can be good at computational decision-making, which can give the best solution when combined with human judgment.

Murray also shares practical advice for digital health startups who are looking to raise VC money. Take a listen.

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Show Notes

01:07About Conversa Health and your involvement with the company.
03:35What is the current state of AI in healthcare?
06:11 Conversational AI tools, especially chatbots, are having a moment in light of the pandemic. What COVID has meant for your company?
09:19 Do you think we are further along when it comes to applying conversation AI in the context of administrative use cases like the ones you describe or do think we are further along with clinical use cases?
11:05 Based on what you're seeing and the work your firm is doing, where is the low-hanging fruit today? Is that in certain types of clinical conditions, for instance, behavioral health?
14:25 Who do you mainly serve – payers, providers, employers? What is your ideal client profile?
16:28 What does conversational AI compete with in the context of a healthcare provider?
20:55Where does the voice fit in all of this? Do you compete with voice-based solution providers like Nuance for instance?
22:49When you talk to your clients, what do you ask them to prepare for in terms of the most challenging aspects of rolling out a conversation AI tool?
25:28What do you see the next 12 to 18 months looking like from the point of view of VC money flooding the market? Also, what is your advice to a digital startup that's on the receiving end of this money?

Q. Can you tell us about Conversa Health and your involvement with the company?

Murray: At Conversa, we are pioneering a new care delivery model – automated virtual care. It sits at the intersection of what is happening in automation and what is happening in virtualization. We think about it as a complement to current care delivery models. It complements in-person, digital, telehealth, remote patient monitoring, etc. It adds a piece of the puzzle that we think has been missing and will be standard of care in the future. I have known the founders of the company for years. We have worked together in different healthcare ventures, and this is my fourth digital health venture. I was involved in companies focused on consumers and patients, providers, and the payer market. I was super excited to join the company to help form the strategy and then take over as the CEO about 18 months ago.

Q. You are a private, VC-funded company. Can you tell us who are your major investors and how much money the company raised to date?

Murray: We’ve raised a little over 30 million dollars at C round, A round, and B round. Our investors are a great mix of supportive investors. We have financial investors, builders, VC, and Northwest Ventures, all the big health system in New York. And then we had other folks who were a combination of strategic investors like university hospitals in Cleveland, Allscripts, Pfive, and other healthcare-focused venture firms in Connecticut. We know the space as well as strategic investors with who we have nice operating strategic relationships.

PP: What is the current state of AI in healthcare?

Murray: The way we think about technology in healthcare, especially digital health, you must build a purpose-built solution to solve the problems. Then in that solution set, see if the applications of AI or machine learning or deep learning make sense to improve what you are trying to achieve. Those tend to be the most successful applications. In image recognition, in radiology a lot of good work is being done with AI. But even there, there is a need to recognize where AI needs to complement actual intelligence from people. There are a lot of studies that show this notion of co-bot. For example, the person working with AI in radiology can identify breast cancer tumors and characterize them. But on the corner cases, we need to have an actual trained professional distinguish and then make a judgment call. So, Garry Kasparov, the chess master, distinguishes between what humans are good at and what AI is good at. Humans are good at judgment, and AI is good at decision-making. Decision-making is computational all the way down, and judgment is knowing what matters and why it matters. If you can get those to work together, I think you have the best solutions. There’s a lot of conversational AI being thrown at natural language processing. If you are modeling physician language well, you can get high accuracy because physicians might use big words, but it’s a very prescribed and precise vocabulary. When you start to step into a patient world, they can say anything, and it can mean anything. You must infer if you are trying to rely on that platform for accuracy to determine whether you need to intervene with the patient, probably not the best approach. So, I think there is a lot of technology in search of solutions and the successful ones have understood the problem deeply.

Q. Conversational AI tools, especially chatbots, are having a moment considering the pandemic. What COVID has meant for your company?

Murray: When you think of conversational AI, there are many applications, but they are mainly administrative ones. For instance, I call a call center, and I am trying to make an appointment and understand my explanation of the benefits. There is some good AI because there’s minimal language, a lot of ability to get you to the right place, and its pure cost savings. It is reducing the number of customer service reps on the phone—a lot of proof points outside of healthcare are being brought in healthcare. There is a category that I would call virtual urgent care where an anonymous patient is walking to the door with symptoms. You need a big database of symptoms correlated with outcomes, and you dynamically update that so that you can decide whether I’ve got COVID or I’ve got a rhinovirus or a cold. There is a bunch of companies doing that. Doctors are primarily skeptical, so they are having success selling the payer market to some employers. The category that we live in is more care management, care coordination, transitions of care, pop health. For instance, you are enrolled in a heart failure program, the AI reaches out to you, talks to you, collects information, and checks how you are doing. It is using an evidence-based pathway to determine whether we can automate the next step, where we need to ask you what the right next step for you is, it’s very difficult to do with AI. The state of the technology is still not there, so we have taken a structured approach. Permutations are enormous, and there could be billions of permutations. Our intelligence is how do I stitch together structured conversations so that it’s personalized for you, and you’ll engage. We can collect the information we need and then use the right nudge, escalate you to the right next level of care. We use the AI/ ML in the prediction piece, it’s not just a chatbot, a chatbot is the user experience, but everything we collect from you could be biometrics, could be Piros, could be informal answers to questions, structured information. We then, in real-time assess that and check what we should do next. We use a lot of AI and ML there to predict if you’re going to decompensate because we’ve seen lung function like this with this characterization from your FEV1 scores and you’re likely not to do well in the next month.

Q. Do you think we are further along when it comes to applying conversation AI in the context of administrative use cases like the ones you describe or do think we are further along with clinical use cases?

Murray: Many things moved forward because of COVID. We’ve got about a hundred and fifty automated virtual care programs running at various large health systems around the country. I would say the clinical has caught up, and the stakes are higher. We strive for one hundred percent accuracy in determining whether a patient can be automated or isolated on the next step. You can’t do that with natural language understanding technologies. It must be a very deliberate and structured approach. But then you have the smarts to understand the status of the patient to make the right decision. Conversational AI in the context of administrative use cases was ahead. But clinical is probably a priority right now, and the opportunity for clinical is enormous. They come together in the mid to long-term future because you would want to have the administrative use cases attached to clinical all via one platform.

Q. Based on what you are seeing and the work your firm is doing, where is the low-hanging fruit today? Is that in certain types of clinical conditions, for instance, behavioral health?

Murray: We’ve conceived this to be a platform, meaning that it needs to work across all the meaningful use cases of a large health system or health plans. So, we have decided to build a platform that can accommodate programs or automated virtual care pathways from chronic care management to post-acute care to perioperative to women’s health, cancer, pediatrics, and in the ED. We have programs in those areas, and we are continually building them. Patients do not necessarily fit easily into one use case; you might have diabetes, hypertension, and suddenly you need a hip replacement. We want to accommodate it, be an extension of the health systems care virtually for patients in a seamless way that has a great user experience and leverages the full 360 views of the patient. So, that is where we are heading. We tend to start post-acute, 30 day, 90-day post-acute programs, and monitor people when they leave the hospital, and focusing on helping them recover and reducing unnecessary readmissions. We want to focus on patients who are walking out of the ED, understanding discharge instructions, picking up their prescriptions, going to their follow-up appointments, really focused on lowering recidivism back to the ED, where it’s not necessarily chronic care management.

During COVID, we worked with UCSF Health in San Francisco and shifted our focus to the vulnerable population. We helped reduce the risk of getting infected from COVID and provide a better experience for patients who could calibrate all the parameters remotely. There are many examples where we have identified decompensating patients, whereas otherwise, they would not have to escalate. And then, like ED, we are also now seeing a lot of interest in targeting both pregnancy and early pediatrics. Behavioral health is another area, it was a pandemic before the COVID pandemic. It is amplified because of that and so that’s another area that we’re getting into.

Q. Who do you mainly serve – payers, providers, employers? What is your ideal client profile?

Murray: We primarily work with a lot of midsize and community hospitals. We are also provider-focused because we want to make sure we understand how to extend a trusted relationship. And we have very high enrollment, activation, and the ability to change behaviors and drive measurable outcomes. So, the way that a patient thinks about it as a health companion. It is a twenty-four by seven extension of my doctor and nurse.

From the provider side, they think of it as an automated care team member who is helping to reach out to all these patients on their behalf and can practice at the top of their license. So, within that model, we have expanded to work with health plans. Our focus with health plans is where they are acting as a provider. We work with them to create programs used by patients and health systems and then for employers, schools, and the community and this got accelerated during COVID. We have many employers and universities using our COVID programs to screen for COVID to manage people who are positive, monitor people who have been vaccinated, and now deal with mental health from COVID. All of it is delivered through our healthcare partners. Our focus is that the health system in your community should be responsible for caring for the community. We are giving them a platform to amplify that help that they are already providing.

Q. What does conversational AI compete with in the context of a healthcare provider?

Murray: As a company that is positioned itself as an enterprise-wide platform. So, we want to be your automated virtual care partner if you are a health system. If you are using automation for administrative purposes, that is complementary to what we do. If you are using it for a digital front door, virtual urgent care, it’s complementary to what we do. So, you are now managing your patients; you’re enrolling heart failure and diabetes patients into programs. Our platform will compete with point solutions. If someone says I have an app that can help manage diabetics, I can come in with an entire stack device and coaches. So, somebody might want to choose that to work with their diabetic population. We say, hey, you can use the same platform to treat your diabetes and cancer patients. That is pretty compelling because health systems increasingly want to consolidate. Working with one partner is easier, and you start to understand patient IDs across the continuum. We aspire to manage patients across a lifetime, which does put us in competition with point solutions in certain areas in the future. Our challenge is to figure out if there is a perfect point solution. How do we integrate it into our platform, and how do we start to allow other solutions to plug into our platform?

Q. Does your tool sit on top of an Omada or a Livongo kind of platform? You also mentioned about clients wanting to consolidate into a one-stop-shop. We see this in our work with health systems, where they are trying to reduce the footprint of vendors, they must deal with because of all the complexities involved. How do you fit in that context, and how do you help your clients work through the tradeoffs involved here?

Murray: Companies like Livongo have chronic care management for diabetes, hypertension, weight loss, and behavioral health. They have devices and coaches wherever applicable. Because it is a service-based company, it tends to be with payers and employers very successful. Most companies with full-stack solutions are doing it because payers and employers do not have clinical resources and devices. Health systems already have clinical resources caring for patients; we want them to be more efficient and effective. It is purely a software platform where devices are involved. If they have an RPM partner, we are complimentary. In the health system world, they do not need the provider networks of any of those other companies. They are looking for technology solutions, and we excel there. When we go into the world of payer and employer outside of the health systems, those companies become partners. So, like Livongo, we can say that if you want to add the conversational AI and decision-making we bring, we can help leverage the platforms that they have built in the same way we do for the system. So, if you aggregate what they do, they have clinical resources like the health system does. They have the device as the RPM’s do. We can bring the piece to the puzzle that we get that table in that world.

Q. Where does the voice fit in all of this? Do you compete with voice-based solution providers like Nuance for instance?

Murray: We do not offer voice today. However, I demo our platform using voice a lot, but I am just using the native voice on the phone to do text or voice. We have not gone there yet because we are very driven by where the market need is, and the impact that we are having is enormous. When we see that people interact with voice, we realize it is not a big thing to add. You want to make sure that you are designing the voice interface as per the requirement. You are not translating a text to voice because understanding what someone is saying with 100 per cent accuracy in voice is a different design requirement than doing it through a chatbot.

People like Nuance probably have the best-known value out there. But it is not an accident that they’ve chosen to do transcription for wires because when you’re looking at what a provider says and being able to transcribe accurately, you can do that. You get into the patient world where a patient can say or respond to anything in that world. The way you would measure it is precision and recall precision, where the recall rates will be 80 per cent at best, which means the error rates are 20 per cent plus. No hospital system will use that error rate to decide whether they can automate the next step for a patient.

Q. When you talk to your clients, what do you ask them to prepare for in terms of the most challenging aspects of rolling out a conversation AI tool?

Murray: We have a very rigorous process that has four different swim lanes. There’s integration, configuring the pathway or the program. Everybody delivers their care delivery model for diabetes to slightly different guidelines. So, there is an integration pathway, there are best practices on how you enroll the patients, and then there is how we’re going to measure success.

Some of our clients are very sophisticated and want to collaborate. We have taken off the table things like NLU and liability. So, the real focus is on making a program that we have designed and figuring out how to deliver care that fits in your model, works in your workflow, and integrates into your data flows.

Q. What do you see the next 12 to 18 months looking like from the point of view of VC money flooding the market? Also, what is your advice to a digital startup that is on the receiving end of this money?

Murray: Markets, in my experience, always overshoot. They are trying to get an equilibrium, but there is a massive bait on both sides. There are unprecedented amounts of money in digital health, and it is concentrated in certain areas like behavioral health, which is a big problem. Every time that happens, we are starting to see a massive consolidation. To your point, companies go public and use that capital very quickly to acquire. Teladoc, Livongo kicked off a big part of that, and there are others like Grand Rounds and Doctor On Demand. There are tens of hundreds of these deals happening, and many companies are getting funded. I think what we will see is continued consolidation, and there will be a whole bunch of companies that don’t make it above the threshold to be viable or to be attractive to be purchased, and they’ll go out of business, or will be acquired. It will happen quickly, and that’ll make the companies that are above there much stronger.

So, advice to somebody coming in the space is it is always better to start in a cycle where things look horrible because that is how you develop your product. If you are starting a company now and get funding, spend this time developing your product and getting product-market fit. Pick a problem because I think there is a lot of technologies out there in search of solutions. The market will give you an opportunity if you can solve it better than someone else or if it is an unsolved problem. Once the product is available in 18 to 24 months, that is probably an excellent timeframe to come out with a product. I am in a position right now where I am not worrying about generating revenue but worried about just building the product, and I have the funds to do it.

You must be doing lots of things, but it all comes down to the patient if they feel it is important in their care and have better outcomes. The providers can care for more patients and spend the time doing what humans can do; then, you have a winner. Those are the only two things I look at to see if we are successful. I look at what patients are saying and doing with the products, and I look at whether providers embrace it. If we have those two things in place, everything else will go well and ultimately; it will be successful.

 

About our guest

Murray Brozinsky is CEO of Conversa Health, an Automated Virtual Care Platform designed to expand access to care, enhance the patient experience, and improve health outcomes. Health systems, payers, and pharmaceutical companies use Conversa to keep patients on personalized evidence based pathways to better health.

Conversa was recently honored as the Best Remote Diagnostics company at the 2020 UCSF Digital Health Awards. During COVID-19, Conversa has also been keeping people connected without getting infected.

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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THE HEALTHCARE DIGITAL TRANSFORMATION LEADER

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

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THE HEALTHCARE DIGITAL TRANSFORMATION LEADER

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