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Incrementalism is not a bad thing in digital health

Posted on by sanjith p

Season 4: Episode #126

Podcast with Tarun Kapoor, MD, SVP and Chief Digital Transformation Officer, Virtua Health

"Incrementalism is not a bad thing in digital health"

paddy Hosted by Paddy Padmanabhan

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In this episode, Tarun Kapoor, MD, SVP and Chief Digital Transformation Officer at Virtua Health talks about the diverse population segments they serve in Southern New Jersey and how they drive digital health priorities and investments. He also discusses how to drive digital health programs in an incremental fashion and gain stakeholder buy-in within the organization for digital health.

Tarun discusses the current state of the digital health startup environment, the longer-term technology solutions landscape, and how to make smart decisions with limited resources. Take a listen.

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Show Notes
00:36 Tell us about your background, how you got into this role, and the populations you serve at Virtua Health.
04:22What are your key priorities for the organization? How does the digital transformation function fit into those?
07:15As the Chief Digital Transformation Officer, how are you directing your investments? Also, how are you factoring in your populations’ expectations from a digital technology enablement standpoint?
16:29What challenges did you have to deal with when you implemented the tech, the data, or the infrastructure?
18:59 There are thousands of solutions to pick from once you’ve designed the experience. Right from the native EHR system, nimble young startups to enterprise-class tech firms and everything in between. How do you make that technology choice?
23:12 What's your advice to startups who are listening to this episode?
25:53 Is there a rubric that you use when it comes to building a case for a new solution where there isn't adequate data for you to say whether it's going to work or not, especially in a margin constrained landscape like health care providers?
28:05 Is there something you’d like to share with your peers?

About our guest

Tarun Kapoor, MD, MBA, is senior vice president and chief digital transformation officer at Virtua Health. In this role, he oversees Virtua’s Digital Transformation Office and orchestrates Virtua’s enterprise-wide master plan in support of an intuitive care journey for all consumers.

Previously, Dr. Kapoor was the president of VirtuaPhysicianPartners™ and the senior vice president and chief medical officer for Virtua Medical Group (VMG), a clinician multi-specialty medical practice. Dr. Kapoor joined VMG as a hospitalist in 2008, where he was the associate director of the Virtua Hospitalist Group, helping grow the practice from 12 physicians to its current size of more than 110 clinicians.

In addition, he joined Virtua’s Medical Informatics team in 2010, helping to develop and implement its inpatient electronic medical record, including full deployment of CPOE and electronic Medication Reconciliation. Prior to joining Virtua, Dr. Kapoor was regional director for EmCare’s Mid-Atlantic Hospitalist Division. During his tenure with EmCare, Dr. Kapoor developed 16 inpatient care programs for Clinical Staffing Solutions, which was subsequently acquired by EmCare. Dr. Kapoor trained in internal medicine at The George Washington University Hospital, where he stayed on an extra year to serve as chief resident and clinical instructor. He obtained his medical degree from Rutgers Robert Wood Johnson, his undergraduate degree in government and chemistry from Cornell University, and his executive Master of Business Administration from the Fox School of Business of Temple University.

Tarun Kapoor, MD, MBA, is senior vice president and chief digital transformation officer at Virtua Health. In this role, he oversees Virtua’s Digital Transformation Office and orchestrates Virtua’s enterprise-wide master plan in support of an intuitive care journey for all consumers.

Previously, Dr. Kapoor was the president of VirtuaPhysicianPartners™ and the senior vice president and chief medical officer for Virtua Medical Group (VMG), a clinician multi-specialty medical practice. Dr. Kapoor joined VMG as a hospitalist in 2008, where he was the associate director of the Virtua Hospitalist Group, helping grow the practice from 12 physicians to its current size of more than 110 clinicians.

In addition, he joined Virtua’s Medical Informatics team in 2010, helping to develop and implement its inpatient electronic medical record, including full deployment of CPOE and electronic Medication Reconciliation. Prior to joining Virtua, Dr. Kapoor was regional director for EmCare’s Mid-Atlantic Hospitalist Division. During his tenure with EmCare, Dr. Kapoor developed 16 inpatient care programs for Clinical Staffing Solutions, which was subsequently acquired by EmCare. Dr. Kapoor trained in internal medicine at The George Washington University Hospital, where he stayed on an extra year to serve as chief resident and clinical instructor. He obtained his medical degree from Rutgers Robert Wood Johnson, his undergraduate degree in government and chemistry from Cornell University, and his executive Master of Business Administration from the Fox School of Business of Temple University.

Q. Tarun, tell us about your background, how you got into this role, and the populations you serve at Virtua Health. 

Tarun: “Wherever you go, there you are,” I think, sums up my journey which wasn’t ever truly planned. I’m a physician by training — Internal Medicine Hospitalist — and I was actually going to be a Gastroenterologist. I had a Fellowship lined up and then, I came to profound realization that I just didn’t really like abdominal pain. So, I gave up the Fellowship before I started and was gainfully unemployed. I ended up joining a startup at a time when hospital medicine was just emerging. So, I was a Hospitalist. We grew a hospitalist company, a business, and then, I exited successfully. Transition points are recurring themes in my journey but from here, I got the opportunity to get connected with Virtua. 

I’ve been very fortunate at Virtua. I’ve had a number of different roles ranging from informatics, being part of the medical group, and population health. In 2019, I was asked to take on an assignment for digital. Since we had done only five ambulatory video visits in 2019, I set the goal for 500. Then, March 2020 came along. As the saying goes, better lucky than good , we were a little short of 200,000 but we did exceed our goal that year. 

That’s the role we created to hardwire into our organization some of those accelerations from digital transformation being produced by the pandemic. How did we do that so as to not revert to the original way of doing things? We created a digital transformation office. I’m so fortunate to be able to head that team.

Virtua created the integrated delivery network in the southern part of New Jersey, right along that Philadelphia latitude. In terms of a market, New Jersey is pretty dense. From the population density perspective, one of the things that’s really interesting is, there is a tremendous diversity in socioeconomics. 

We have some of the more affluent neighborhoods. One of them actually has two Apple stores within 10 minutes driving distance of each other. Seven miles away is Camden, one of New Jersey’s most disadvantaged communities. It’s just a startling fact that the life expectancy among those seven miles is 16 years. That’s important for us to think about and include in our digital transformation. We’ve got to make sure that what has continued to probably create inequities does not continue to accelerate forward. 

Q. What are your key priorities for the organization? How does the digital transformation function fit into those?

Tarun:  Some of the key priorities I’ll list are probably not that different from many of the other integrated delivery networks. There have been these remarkable swings since 2020, a tough year that saw many business operations shutting down resulting in essentially suppressed demand. 

2021, for us and a number of health systems, saw a dramatic rebound of that demand. It’s likely that that suppressed demand from 2020 was coming into 2021. Then came the Omicron surge which actually hit us—from a volume perspective—harder than the first surges did. What a tough first quarter for that from the perspective of economics and running the business! Now again, it’s rebounding. 

One of the things that is really an important for us here, is understanding market volatility. That is not classically something you would think about in healthcare. That was always the story about healthcare. People are always going to be sick and so, will always need healthcare. It’s a recession-proof business. It’s anything but, and is being impacted more than ever before. 

Going one step further, it’s critical to understand that the demand for healthcare is actually way more elastic than anything we realized or expected. We didn’t understand why it was so during COVID. We literally did not see strokes, for example, at nearly the same volume before. I mean, you have a stroke. You’d think people would come forward with these symptoms. It’s alarming. 

That prompted some deeper questions about what was truly happening with our consumers, our patients. That consumer focus and trying to understand their needs is what’s really and hopefully driving for us what we’re trying to take apart. 

Q. Given those priorities, how are you, as Chief Digital Transformation Officer, directing your investments? How are you factoring in these significant differences in your populations and their expectations from a digital technology enablement standpoint? 

Tarun: One hundred percent. Within the priorities in our Digital Transformation Office, I will quote a formula that we stole from someone who we know stole from somebody else. I’m not exactly sure where the true origins lie but that formula is: NT+OO=COO. Memorize that formula because it continues to keep our standards. 

What does that mean? New Technology + Old Organization = Costly Old Organization. 

We have a budget for digital transformation. If it was as easy as buying a technology, we would have all transformed at this point. But if you simply just buy technology and you wire it in to the existing organization, basically you’ll just be an expensive version of what you were, previously. 

And if we were previously good at what we were doing, then why are we doing the digital transformation? Yeah, we try to spend a lot of our time from our priorities on understanding the operations and where lies that mismatch between what the consumer is truly asking on one end and how we provide it today. Then, we see what are the ways we can transform. 

With regard to my title, Digital Transformation Officer, I would say the T in that title is the capital letter. What is the transformation that has to occur? Where does digital come into it? Where’s the operational change as a company? Sometimes it’s going to be a real problem and at others, the digital is ready while the operations is not, for the transformation. Sometimes the operations may be ready while the digital isn’t. That match is crucial. We spent a lot of time asking, “Is it ready?”, and that’s where we’ve been successful, so far. 

Q. Can you cite examples of how you’ve implemented this thinking in practice at Virtua? Where do you start – with a journey map or company research or something else — before you eventually land the technology? 

Tarun: I don’t think I have one very good answer. In fact, rarely is there a right answer. However, there are usually a few wrong ones to start with. If you must, try to avoid the ones that are pretty clearly wrong. That helps you call the field and then, you just have to pick something and go. 

In some cases, yes, you do your consumer research, get focus groups, and get data back. But don’t get paralyzed by saying, “Okay, I need more data.” Get it, make an educated guess, and get a prototype out there. Then, get feedback and do the five iterations into it. That’s when you actually start to realize that’s what the person’s after.

This concept of agile design in software has been around for 20 years. Agile design doesn’t happen in an integrated delivery network. If we, in health care, can specifically start thinking along these more rapid iterations, it’s very uncomfortable for us because as physicians by training, one part of the Hippocratic Oath in our statement agreement on the theory, says, do no harm. You’d never hear that in a software development company. They’re completely fine with it being, “No, that was a bad idea.” We, however, have to find a balancing act. To me, it was a bad idea. But it was safe. However, that just didn’t make the mark. One example would be online scheduling. 

We’ve had online scheduling technology but what we realized as we started digging deeper is that there was a complete mismatch between what the consumer was seeing and what the doctors and our medical groups had in their schedules. The analogy I’ll give you is if you called the office saying “Let’s use an airline,” and if you called say, American Airlines, the ticket agent would see all the seats on the plane if you were physically at the ticket counter. But if you went to the website, you’d only see rows three and four. 

How is that online scheduling? This could be described as one of those moments when “it was on, but the operational piece had not evolved.” So, what we went from is doing around 13,40,000 online scheduling appointments per year to doing 13,14,000 per month. That’s within about 12 months. Thousands of phone calls and people making their own appointments had a downstream impact both from a revenue and a cost perspective and it’s been enormous. 

Q. Online scheduling is a fantastic use case. What were the challenges you had to overcome? 

Tarun: An analogy I’d like to use is, the fear factor. Do people necessarily resist change because they don’t see the promise? No. Most people will say, “Yeah, I can see the promise.” But the question is, I can also tend to see and specifically, having worked with physicians it comes down to our residency training, it’s gladiatorial training. You do X, Y, Z, QW5. Patient survives. 

Now we’re saying, “Hey! Listen, skip a couple of things. Don’t go through this convoluted path. Just go from here to here. It’ll be fine.” I know if I do this every single time, I’ll get a good outcome. The question then, comes down to trust. 

For us, with our clinicians, we say, “Okay, help us understand what makes you worried about putting your schedule online?” The biggest fear over and over was, “I am worried that the wrong appointment is going to get booked.” What that means is, it’s a brand new patient who’s put into an established slot. With new patients, clinicians need half hour, 45 minutes longer. With established patients, perhaps it’s a 50 tweet I’m behind already. That happens first in morning. I’m catching up all day. 

That was something we could work towards. If you get in with it, you always want to have your early adopter folks. You just let them go. Your late adopters are going to be really hard, but you can get the momentum in between. That’s where it is and that’s just working. We say, “Let’s do a couple. Turn it on for a day. It’s not a big bang approach. Just turn it on for a day.” We ask “How’d it go?” and then, just turn it on for two more days. 

It sounds painful and iterative, but the reality is that’s how change happens. I just sit back now. It’s like an Atul Gawande article — slow ideas — everyone wants everything to go viral, and when they do, it’s wonderful. 

But some things don’t go viral and you’ve just got to work with people and meet them where they are. 

Q. Let’s touch upon the technology enablement aspects. What challenges did you have to deal with when you implemented the tech, the data, or the infrastructure? 

Tarun: I had put this in my LinkedIn profile. I don’t know if I came up with this de novo or sublimely, I stole it from somebody else. But I’d heard the statement “Culture eats strategy for breakfast.” If that’s the case, then, workload eats technology for lunch, dinner, and dessert right here. You ask someone to swivel between screens, and I already know the impact of what I want to get if I swivel to another screen, to another log in, even if it’s single, sign on. I already know the voltage drop is going to be enormous. 

The other question we try to ask is “So what?” Maybe there’s a nicer way to ask it, such as “If I do this technology, what am I going to get for it? What’s the proposed return?” 

One of the things our team uses — whether you use a balanced scorecard or you have smart goals — are OKRs (Objectives and Key Results). We ask, “What are my leading key results? What are my lagging key results?” 

If I put this in, one of these numbers has to move. The other thing we do from a technology perspective if it’s not moving, is, check “Are you prepared to rip it up?”

Yet another thing we also do is for every one thing we bring in is, we rip out at least one or two others because it just cannot be this. I think about this poster from the 1980s — He who has the most toys wins . That’s not a viable solution for us in this space. 

Q. There are literally thousands of solutions to pick from once you’ve designed the experience. Right from the native EHR system and nimble young startups to enterprise class tech firms and everything in between. How do you make that choice?

Tarun: Especially given that the frothiness of the investment market has normalized for now, I can certainly give you a framework. We look at different things that are important for us — not everything can be transformational — and incrementalism is not necessarily a bad thing. 

So, we go, “Hey! Listen, we just need to get a little bit better at this.” We need to constantly iterate and I would think of something like order sets. You have to make orders better. I’ve got to make some of my other functionality within my EMR better. That’s incremental and important. You can’t stop that. That’s not where our sharp focus is. We try to focus on five or six major transformational things and we have to stay so. 

One of the problems we had and one of the mistakes we made early on is we didn’t say “No” enough. I am trying to say “No” a lot. If you really want to do this as an operational owner, you have to prove to me what you’re prepared to do, to do this. I can’t make the change for you btu I will make the change with you. It’s how we think about it. 

When we look at technology, I think we look at it as “Is this a problem that one of our existing solutions can either solve today or in the next 18 months? Somewhere in that window?” It’s a little bit different depending on the problem. 

If it can be solved today with an existing solution, then, to go outside of that world, you really need to have a really good explanation for why someone would want to go with a tool outside of that. 

If it can be solved but not today; and if one of our existing tools has a good road map to get there in the next 18 months, then, it’s a decision around the severity of market need. What’s the market demand on that one? 

Then if you say no, we feel pretty confident it’s not on the roadmap or two years out. Then, we’re open to go looking with a startup or a partner. We’re trying to answer this question that states very transparently that we don’t sign ten-year contracts. 

You have to constantly keep proving yourself because the reality is, one of those native systems that we had on our native platforms eventually is going to catch up. It’s probably been on offer for a fraction of the cost of what the startup is. For example, video visits. We were paying hundreds of thousands of dollars for video visit solutions. Now we’re paying $0.28 for one video visit. Purely click as you go.

So as the commoditization happens, the startups have to continue to say, “What is the problem I am trying to solve?” You may have a good contract right now but you have to work out the assumption in three years. That’s a problem someone else may have solved for cheaper. It’s been commoditized. However, take the learnings you’ve had by partnering with the health system to say, “Okay, what are the problems? I’m going to help you solve that.” That’s an approach that I think of when we look to partner with folks. 

Q. What’s your advice to startups who are listening to this? 

Tarun: What is the reality of the world? I don’t think there’s anything I’m saying on the health care space that’s any different than any other space. Everything in health care is side-aligned — you got the big five in their respective areas. 

When talking to startups, I ask, “What’s your exit strategy? Between being lean and being acquired by Optum.” That is literally when half of the store doctors go, “Yeah, that’s our only choice.” 

With some of the startups that I’ve seen and worked with, once you get acquired by Optum, you get pitched and pulled into that space. It changes the dynamic of the original relationship because in some cases we want to work with people who are independent and outside of the ecosystem. 

In some places, it just makes sense for it to be part of the ecosystem. It’s important to be mindful of and check, “Am I sitting in a space that benefits me being somewhat separate from the big ones or complementary or eventually tied in?” That’s because I think there’s a big misnomer in health care I.T. that the health systems are flush with cash. 

If you think that’s the case, you can look at our P&L record. They’re all wrong and almost all not-for-profit. We’re talking low single digit operating margins. So, it was a bloodbath – though that may be a strong word. It was very difficult and tight. 

Each day you have 10,000 people leading the commercial insurance world where that pays better compared to the Medicare world. So, it comes back to that value proposition of what you’re truly bringing. 

Q. So that obviously begs the ROI question Are you making a lot of digital health investments? Is there a rubric that you use when it comes to building a case for a new solution where there isn’t adequate data for you to say whether it’s going to work or not, especially in a margin constrained landscape like health care providers?

Tarun: I wish I could say, we put data into an Excel spreadsheet and a formula comes out and scores 99. We go with it and it comes out with a six. We don’t. I will tell you though that, there are some gut calls you’ll get at times. We won’t leverage the house on a gut call. But I think one of the things we’ve stated, though, is our investment in digital and our thesis is very clear. Any incremental investment has to help us gain consumers who want to be part of our health system, retain consumers who, if we don’t offer this, are going to find another solution that meets their value proposition. And then, it has to be real, tangible savings. 

You can’t be this soft. Sometimes I look at some of the valuations and the ROI calculations people come up with. It’s like, “We’ll save you half a day in the hospital, which will then, lead to $10,000 of savings.” I think “Yeah, maybe you’re off by like two decimals there.” It has to be hard. Tangible.

Q. You’ve been in this role now for two or three years. If there’s something you’d like to share with your peers listening in, what would those be? 

Tarun: I’ll give two. I think they’re probably the same thing, but maybe slightly different way of saying it. 

I mentioned I was in a startup, and when I first came out of training, one of my mentors gave a statement that one of his mentors gave him, and that is, “no one ever went out of business because they focused too much.” Now, you may not be the biggest business. You may not be getting on the speaking stages, and you may not be on the cover of X, Y, Z magazine, but you’ll still be in business. 

A corollary to that is a term we use in our organization. Specifically, my team is called Coldblooded Execution — There’s a lot of cool, a lot of talk, but at the end, those who execute will win and there will be winners and losers in this space. We’ve seen it over the last couple of years and it will only continue to accelerate. That is relatively new for integrated delivery networks. There are integrated delivery networks who are essentially either are going to get acquired or in some cases shut down because they did not thrive in this business. But cold, hard execution ideas are wonderful. Execution wins. 

We hope you enjoyed this podcast. Subscribe to our podcast series at www.thebigunlock.com and write to us at info@thebigunlock.com

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

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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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Voice technology will enhance care delivery from within the EHR

Posted on by sanjith p

Episode #57

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

DN: Thank you.

YK: Thanks for having us.

We hope you enjoyed this podcast. Subscribe to our podcast series at  www.thebigunlock.com  and write to us at  info@thebigunlock.com

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

About our guests

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

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

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

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

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

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

Posted on by sanjith p

Episode #56

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

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

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

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

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

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

MB: Thank you very much, Paddy.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

We hope you enjoyed this podcast. Subscribe to our podcast series at  www.thebigunlock.com  and write to us at  info@thebigunlock.com

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

About our guest

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

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

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

Posted on by sanjith p

Episode #55

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

We hope you enjoyed this podcast. Subscribe to our podcast series at  www.thebigunlock.com  and write to us at  info@thebigunlock.com

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

About our guest

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

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

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

Posted on by sanjith p

Episode #54

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

We hope you enjoyed this podcast. Subscribe to our podcast series at  www.thebigunlock.com  and write to us at  info@thebigunlock.com

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

About our guest

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

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

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

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

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

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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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Emerging healthcare technologies will enable higher level of care delivery with fewer resources

Posted on by sanjith p

Episode #53

Podcast with Jeff Short, Vice President and Chief of Staff, Montefiore Health System

"Emerging healthcare technologies will enable higher level of care delivery with fewer resources"

paddy Hosted by Paddy Padmanabhan
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In this episode, Jeff Short, Vice President and Chief of Staff at Montefiore Health System describes how Montefiore prepared for one of the biggest surges of COVID-19 cases in the country, and how they used emerging healthcare technologies to manage capacity and deal with the crisis.  

By end of April this year, 80 percent of all patient visits in Montefiore were being managed through telemedicine. Telehealth visits volumes have fallen back a bit since then. Jeff believes that face-to-face visits in certain specialties will always remain essential, however, with the ease of working with patients digitally, we will continue to see an increase in telehealth visits. Jeff defines digital health as the use of technologies such as digital front doors and telemedicine to improve patient engagement and access to care delivery. He further states that once we get efficient at delivering digital care and leveraging emerging healthcare technologies like chatbots and AI, we will be able to treat more patients at a higher level of care with fewer resources.

Montefiore Health System is one of the leading medical centers with 11 hospitals and over 300 ambulatory locations. They mainly serve the populations in the Bronx and Westchester counties.

Jeff Short, Vice President and Chief of Staff, Montefiore Health System in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “Emerging healthcare technologies will enable higher level of care delivery with fewer resources”

PP: Hello again, everyone and welcome back to my podcast. This is Paddy, and it is my great privilege and honor to introduce my special guest today Jeff Short, President and Chief of Staff of Montefiore Health System in New York. Jeff, thank you so much for setting aside the time and welcome to the show.

JS: Thank you, Paddy. I really appreciate the opportunity to be here. I want to congratulate, as you recently completed your fiftieth podcast. So, congratulations! That’s really a great milestone and I’m also looking forward to reading your new book, Healthcare Digital Transformation. It’s where we are, so I can’t wait!

PP: Thank you. I greatly appreciate that. So, Jeff tell us a bit about Montefiore and the patient populations you serve.

JS: As you mentioned, we’re in New York. Montefiore Health System and Einstein College of Medicine form one of the nation’s leading academic medical centers. We have 11 hospitals, approximately 3000 beds, and over 300 ambulatory locations. We serve mainly the populations in the Bronx and Westchester counties. We are major employers in both geographies, we serve a diverse population both ethnically and socially. And it’s been an incredible experience working with Montefiore and seeing all the good that we do in the communities that we serve.

PP: If I’m not mistaken, you also serve possibly one of the most ethnically and linguistically diverse populations in the country, if not the most diverse population. Is that correct?

JS: Yeah, depending on how you measure it. But definitely one of the most diverse populations in the country.

PP: New York has been one of the hardest hits by the pandemic, and Montefiore was featured in this fascinating TV program on CBS. Those who haven’t seen it, I strongly recommend it. It’s called ‘Bravery and Hope’, which took viewers like me to the frontlines of the COVID-19 crisis and was an eye-opener to see what really happened in the frontlines of a crisis like this. So, Jeff I know that Montefiore stood up telehealth operation practically overnight. Can you tell us a little bit about that experience?

JS: CBS did an incredible job of capturing what it was like during the surge of the pandemic. In the days prior, we spent a lot of time preparing. One of the things our network performance group did was to regularly update predictive models based on what was going on in Italy and around the world and in New York. When we looked at the numbers, we realized it was not going to be a linear increase. It was going to be an exponential increase. I remember one day looking at those projections and realizing that we could be out of capacity in a few days and out of our surgeapacity a few days after that. It really hit home how we needed to change. We knew we were going to have a wave of patients coming, we didn’t have steep, but it looked pretty daunting. Our facilities team did a great job by extending capacity. We put new rooms in our ORs, cafeterias, auditoriums. We redeployed a lot of our clinical staff. But the real question was, how are we going to leverage our intensivists to treat all those patients. We knew we’re going to need that level of care. One of the people featured in that video, Dr. Michelle Gong, who is our Chief of Critical Care, worked with our team and with IT and bioengineering. In a span of a few days, the team stood up a 24/7 ICU command center. My team put together a new server to feed healthcare information and healthcare records to a central location – Bioengineering linked, real-time, vital signs, ultrasound results, electrocardiograms. To all the physicians in our ICU command center, we gave iPads out to each unit. This way they could do bidirectional communications by the command center. So, when we were done, essentially what happened was a clinician anywhere in the facility could connect with one of our critical care pulmonology specialists in the command center for assistance with the patient. In a span of mere days, we went from nothing to a fully functional ICU command center, that really helped us deal with the surge capacity.

PP: That is an incredible story. What about the patients? What about those who wanted to either come in because they felt they had symptoms or others that were in your care, like the chronic population and so on, because you obviously locked down the entire facility for a period of time like everyone else did in order to deal with the COVID-19 cases. Did you already have or were you able to turn on a telehealth/ virtual concept kind of capability to help your patients?

JS: Yes, absolutely. In the early days, no one wanted to go see the doctor for elective care. Nationally, over 70 percent of in-person visits were canceled and we saw the same experience here. Lucky for us, the CMS approved 80 new services within a few weeks of the pandemic hitting the US, which was really fantastic. But what we needed to do is create a new solution. So in about a week, March 11th was our first patient, we started to get things in place to create the ability to deliver contactless care to our patients. By March 26, our team built the infrastructure to enable us an Epic to schedule document and bill for a telemedicine visit. We identified our partners to help us build a platform and an app. By April 1, we had launched what we call Montefiore First, which is an app platform that is in Android and the Apple store. And by June, it was among top 100 medical download on the Apple store. So, by the end of April, 80 percent of our visits were in telemedicine. Right now, it is shifting back a bit. But in the last 12 weeks, we have had 250000 telemedicine visits. In February, we had zero. We went from zero to doing most of our visits in telemedicine quite quickly. And, we’re really not alone, across the industry, we have seen 50 times to 150 times increase in telemedicine.

PP: I want to go back to one comment you made very briefly, that is you’re seeing telehealth visits kind of fall back a little bit. We know that the acceleration of telehealth and specifically virtual consults and everything took off in the immediate wake of the pandemic. But I am hearing from across the board that those volumes are now kind of going down a little bit, either because patients are coming back into the hospital or because there is not that much need. What is driving that? Why do you think telehealth is going down? Was it because pent up demand for in-person visits is now coming back? Or are people not happy with Telehealth as an alternative? What do you think is the reason?

JS: I think it is in part of patients that needed to be seen face-to-face. We’re putting off care. So, they’re definitely rushing back in. I think for certain clinicians and certain patients, there’s a comfort level with face-to-face. But I do really think that things have changed permanently, and the change is here to stay. Before the pandemic, a survey done by McKinsey stated, 11 percent of patients were interested in telemedicine, post-pandemic 76 percent, the same survey updated. We’re interested in using it going forward. We will always have face-to-face care and certain specialties will remain that way. But as we get better and more comfortable working digitally or remotely with patients, those numbers will continue to increase. Also, as adopters become more comfortable, as technology providers create more in-home devices that are linked through your smartphone and operate effectively, we’ll be able to do a lot more remotely. But I do believe it’s here to stay.

PP: You mentioned digital, digital health is all the rage now. We talked about telehealth, digital front doors, and just virtual care in general, which is enabled by technology. How are you defining digital at Montefiore and what has been your digital transformation journey so far? Can you share some of that?

JS: Digital health can encompass a lot of things. For me, in this context, it’s basically using technology to enhance the quality of access or the delivery of care. But to be more specific, the general areas that we’re looking at our digital front doors using technology are to improve patient engagement, to enable contactless interaction to increase access, the use of telemedicine, which we just spoke about. It has profound opportunities to reduce the cycle times of care. With remote monitoring, there’s so much we can do that you don’t need to come back in just to monitor condition if we can check in with you remotely through technology. In tele-consult, the ICU example creates incredible ability to keep patients in a regional hospital, a local hospital and deliver top level of care remotely. Artificial intelligence: Dr. Parsa Mirhaji in our team has made incredible strides in using artificial intelligence to predict things like respiratory failure. What we see is that opportunity to use AI in many more ways and build those into systems. We stood up a chatbot to answer COVID-19 questions. We see a lot of new startups using that technology in front of visits to help the patient and the clinician get to the root of the problem and also improve their interaction. We see huge opportunities to leverage AI. And then the same deal with inpatient. So, hospitals around the country are looking at doing central stations, whether there is AI and other technology to better run their hospitals. And we see this as a huge opportunity. We’ve made a ton of progress in a short amount of time, especially on telemedicine, digital front doors, and also some of the remote monitoring on the inpatient side. We really have a long way to go. But it’s very exciting.

PP: You’ve covered most of the high value, high impact initiatives. And the focus areas you talked about remote monitoring, digital front door, which is growing as digital engagement touchpoints become more and more amenable to digital engagement, online tools and so on and so forth. And, of course, telemedicine and virtual care. How do the patients perceive it? One of the things that I hear from all the health systems and the Chief Digital Officers and everyone that I talk to is that it’s extremely challenging to create the kind of seamless experience that we are used to, like e-commerce Amazon or your personal banking site. It is very difficult to create that kind of experience in healthcare. It seems to me that there’s a lot of standalone best in class type tools. Then there’s a dominant EHR system in the background that does a lot of things, stitching it all together and creating those experience journeys which feel seamless and can delight patients just from an experience standpoint that seems extremely challenging. Is that consistent with your understanding of the challenge as well? What are you seeing in terms of how patients are reacting and responding to your digital front door initiatives, for instance?

JS: Telemedicine has struggled for years to really get adoption. COVID-19 has changed the landscape through which now clinicians and patients were encouraged or forced or compelled to give it a try. Obviously, the ultimate goal is to have that seamless experience. But it’s something we’ve been working on in healthcare and made a lot of improvements over the last few years. I think it is somewhat like when I traveled a lot and the first time I encountered an airline kiosk, when I arrived at the airport, I was really unhappy with the change, not being able to deal with the person, but probably the second time I never really wanted to interact with an agent again unless I had a major, complex problem that I needed to deal with. As long as we continue to seek out clinician and patient feedback and very closely monitor where the pain points are and where our opportunities are to improve and build those in very quickly adapting to the patient experience, but also meeting the patient where they are. So, whether you want to do an asynchronous visit, a synchronous video visit, or you want to see a physician face-to-face, it’s really seamless. And if you want to speak to someone on the phone or go at 2:00 in the morning, do something on your cell phone or your laptop, no matter what we’re meeting the patients where they are and like you said, giving them a seamless experience. It’s just going to be like any other customer experience. It is really going to be listening very closely and getting good data on how patients feel. And again, just iterating to make things more seamless and more effective.

PP: You mentioned a couple of examples of digital initiatives that you’ve launched, chatbot, for instance. Have you done any research into what your patient populations value or what your own caregiver’s value and need? When you look at the digital engagement opportunities, can you talk about one or two of those that you think have high impact possibilities in the short term?

JS: Sure. We’ve done a number of surveys, interviews. We have active working groups that get together every week and walk through their experiences and their problems. We’re adding on to our application ways to get customer and clinician feedback at the moment to better understand their experience. When we look back at our priorities, telemedicine has drastically changed the way we deliver ambulatory care and that is just a key opportunity. We are able to actually bring care into the patient’s homes at scale effectively and efficiently. The digital front door, the ability to gain access from wherever you are to a clinician in a smart way is top of the list. I believe that on the inpatient side, telemonitoring, tele-ICU is a better way to deliver care. And we experienced that during the pandemic and the surge.

PP: You also mentioned contactless experience, which I think is a new beast that we have discovered as a result of the pandemic. But what about your patient population? You are in New York, part of your operations is in the Bronx area, which is kind of a low-income area in the least in some parts. Does your patient population have certain preferences? Do you think you need to tailor your strategy, keeping in mind what are the limitations that maybe with your patient populations, or do you think that is not a factor at this time?

JS: It’s an absolute factor. I mean, the access to and comfort level with cell phones or computers is definitely something we’re looking at. And where there may be disparities in how we can actually address that. Also, access to data that seems to have been an area where patients are concerned about data charges. We’re figuring out other ways we can improve access. Living in a city this could be a great infrastructure type project to provide broadband access to patients for healthcare and could be an absolutely incredible opportunity. We realized little things that people not wanting to download apps. Are there ways we can get them broadband access, even just comfort level using a mobile phone for this purpose? And we’re kind of combining all these things to really create different options and then monitor which options are most successful. And then doubling down in those areas. We’re expecting it’s going to be different by different groups, different age groups, different specialties. And we’re just going to keep listening and looking for opportunities to improve.

PP: The digital divide that you talked about. This an interesting point, because clearly not all sections of the population have the same access to bandwidth or the affordability aspect of it as well. In Chicago where I live, there’s a public-private kind of collaboration that is emerging where there’s going to be a program to make sure that the coverage of the entire population in terms of their access to broadband is going to be uniform. So that there’s no digital divide, there’s no sort of disparity. Are you seeing anything like that emerging in New York? During the pandemic itself, there was a lot of public-private collaboration. Can you talk a little bit about that? I think it’s an interesting trend that is emerging. What your experience has been collaborating with local authorities.

JS: Absolutely, it was really one of the incredible things to see. From the start, the governor’s office essentially stated that we are one healthcare system, they really lined up everything essentially around the same goal, which was the surge that we were going to see, that did a pretty good job of predicting how things were going to play out in the early months. That spirit of collaboration really ran through a lot of things that we worked on. We worked with local vendors, we worked with other hospitals, it was really incredible to share the knowledge and ideas. And we were on the phone with colleagues understanding and sharing best practices, sharing how we’re working together. So, that spirit of collaboration continues. It was always there somewhat in academic medicine, but it’s kind of expanded more to people caring for their communities and can be defined in a number of different ways. We’ve got a couple of discussions going on with companies really trying to bridge that digital divide, because there’s so much evidence out there that does exist. And it is an equalizer that if we can bridge that gap, we can do a lot of good and create a lot of value, not just in healthcare, but also in education, etc. I’m hoping that’s an area where we can really collaborate and do public-private partnerships in order to create a lot of value.

PP: Everything in healthcare is linked to reimbursements in some way. And you did make reference to the fact that the CMS has brought telehealth visits on par with in-person visits. There are still some gaps in the reimbursement model. The broader question is, all these investments that you talked about, the digital front, the tele-ICUs and all of that have to be paid for in some way, shape, or form. So, you have to demonstrate some kind of ROI. How does a health system approach this typically, especially if you are predominantly in a fee-for-service kind of a model?

JS: It’s one of those things we’ve always struggled with as an industry and some of those unintended consequences of how incentives are structured. I guess where we start with is really what’s right and best for the patient. And then we figure out what options we have. The nice thing about our size and our scale is we have a couple of ways economically to get to create value for the business model. So sometimes because it’s the right or efficient way to use resources, it may take a haircut on revenue. But try and take a step back and look at the whole picture. What kind of value we can curate for our patients? Where are these gaps and maybe how the incentives are structured? And then what can we do to kind of either countermeasure to deal with those gaps, work on waivers, try to be creative in trying to deal with those gaps. But it’s something we’re constantly working on, constantly looking for new ideas and new innovations to address those gaps. I think ultimately around the reimbursement for digital health needs to be about equity and payment. I think once we get much better and efficient and effective at delivering digital care, we’re going to find ways to leverage technology like chat technology and AI and be able to treat more patients at a higher level of care with fewer resources. I think at some point what we want is our payment models to recognize that and balance that. So, yeah, and that’s why that’s one equity, I think is really what we want to get to and try and get away from the gaps that we have that cause some of the barriers to innovation and to delivering care.

PP: There’s a saying that never waste a crisis and we are going through an unprecedented crisis because of the pandemic. Are you seeing COVID-19 as an opportunity or as a long-term threat for your system?

JS: I think it’s both. It’s a tremendous threat. I mean, we had a tremendous loss of life. We had employees, colleagues who passed away from this awful disease. Our industry has taken a real hit. The local economy and national economy have taken a tremendous hit. But all those things are done. So within that, there’s an incredible opportunity to do better. To accelerate change, to challenge the status quo. I mean, look at all the things that we have been able to really make progress in the industry. We’ve made so many improvements and we’ve had so much innovation last few months. We have to take advantage of this crisis. We’ve paid the price; might as well take advantage of the opportunity to really accelerate the innovation in healthcare and really bring it forward. So, the answer is it’s both, unfortunately.

PP: Jeff, it’s been such a pleasure speaking with you. Thank you so much for sharing your thoughts and look forward to following all your progress and all the best with your digital transformation program.

JS: It’s been great speaking with you and I look forward to catching up soon.

We hope you enjoyed this podcast. Subscribe to our podcast series at  www.thebigunlock.com  and write to us at  info@thebigunlock.com

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

About our guest

Jeffrey-Short_pic-profile

Jeffrey B. Short is Vice President, Chief of Staff of Montefiore Health System and the leader of Montefiore’s Faculty Practice Group. Montefiore is one of the leading academic health systems in the country with 11 hospitals, 300 ambulatory locations, 35,000 employees and 6 million unique patient encounters. Montefiore’s Faculty Practice Group is one of the largest in the country with over 1500 physicians.

Jeff received his BS in Accounting from the University of Scranton, and his MBA from the NYU Stern School of Business. He came to Montefiore from NYU Langone Medical Center, where he served as the Department Head for Strategy and Business Development. Earlier, Jeff worked as a management consultant for 13 years with both Deloitte and PricewaterhouseCoopers. At PwC, Jeff was a Director and regional leader in the strategy and enterprise growth practice, working with clients such as the Cleveland Clinic and John Hopkins Medicine. He also spent 3 years in Europe leading business development and healthcare engagements with clients in the Middle East and Europe.

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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 nation needs an automated, real-time, effective syndromic surveillance system to detect COVID-19.

Posted on by sanjith p

Episode #52

Podcast with Mike Alkire, President of Premier Inc. and Dr. Jonathan Slotkin, Vice Chair of Neurosurgery and Associate Chief Medical Informatics Officer of Geisinger

"The nation needs an automated, real-time, effective syndromic surveillance system to detect COVID-19."

paddy Hosted by Paddy Padmanabhan
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In this episode, Mike Alkire, President of Premier Inc. and Dr. Jonathan Slotkin, Vice Chair of Neurosurgery and Associate Chief Medical Informatics Officer of Geisinger discuss how technology and data is helping public health officials to keep a balance in opening the economy versus managing the spread of COVID-19 virus.

Premier recently launched a syndromic surveillance tool for COVID-19 which they are piloting at Geisinger to improve the quality of medical interventions and prevent the spread of the virus. Mike believes that there is a need for syndromic surveillance system, contact tracing, and performing tests with higher accuracy rates.

According to Jonathan, siloed information and disparity in EHRs across health systems limits the scope of innovation and in case of COVID-19 it is affecting patients directly. He further states that, as part of a public-private partnership, Geisinger is performing contact tracing and have followed up on 1,600 COVID-19 positive patients, benefiting patients, providers, and communities.

Mike Alkire, President, Premier Inc. and Dr. Jonathan Slotkin, Vice Chair of Neurosurgery and Associate Chief Medical Informatics Officer, Geisinger in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “The nation needs an automated, real-time, effective syndromic surveillance system to detect COVID-19.”

PP: Hello again everyone, and welcome back to my podcast. This is Paddy and it is my great privilege and honor to introduce my special guests today, Mike Alkire, President of Premier and Dr. Jonathan Slotkin, Associate Chief Medical Informatics Officer and Vice Chair of Neurosurgery at Geisinger. Dr. Slotkin also has a dual role with Contigo Health as the Chief Medical Officer. Gentlemen, welcome to the show. Tell us a little bit about the COVID-19 surveillance tool that Premier has just launched, and you’ve started piloting it at Geisinger.

MA: Paddy, over the last year or so, we have been building out technology to help with the PAMA guidelines, which are guidelines that CMS is implementing to get after high-cost images. The focus has been on building up these pipes to Epic and Cerner and these electronic medical records to ensure that patients were appropriately utilizing these high technology images. So when COVID hit, we sort of pivoted the technology. And because we already had the pipes built into all the EMRs, we found out that if you looked at the symptoms of patients, there are a number of characteristics around the symptoms that you could see that there is a high probability these patients were COVID patients. And we thought that it was incredibly meaningful because we could do it in real-time. So, at the point when the physician is meeting with that patient, we can identify somebody that has those critical symptoms. Given that data, we can dive down into the zip code level. We can use that data or get that data to organizations that are interested to understand where surges are occurring or where there is a high prevalence of the disease. Also, there’s obviously a lot of interest on behalf of the federal government and the states to understand where surges are happening. The whole idea is to provide this real-time data mechanism to inform these public health officials around “do I open the economy” or “do I keep it shut” or “open in some degree, but I see a surge, am I putting the appropriate resources in those communities?” We think it’s very, very critical and it’s part of a three-legged stool. We think, to manage the virus you need this syndromic surveillance. We obviously think you need this contact tracing. And we need to do a better job of rolling out testing with higher accuracy rates.

JS: Paddy, the problem we all wanted to solve for is that existing syndromic surveillance in 2020 is dramatically lacking. I think it will surprise many of your listeners when they hear what those systems actually consist of. So existing state and federal syndrome surveillance consists largely of reactive, non-real time reporting of disease diagnoses. And by the way, that are picked up mostly by emergency departments. These tools run on 20-year-old technology and are not automated. And in some areas, clinicians and public health officials actually need to print data from EHRs, manually fill in, and fax reporting forms to public health officials. Some of these forms take up to 30 minutes to fill out. And in some instances, the lag between a patient receiving a positive test result and the reporting of that data can be as long as seven days. And Paddy, you’ve spent a lot of your career on this problem. We’ve troves of important data like positive COVID results, signs, symptoms, but sitting in siloed EHRs across different hospital systems in care settings across the country. So, the nation desperately needs an automated, real-time, effective national surveillance system, and that was the major impetus for this work. The team set out to build exactly that and the goals were to build an application that can be used by a health system, states, and federal government, just like Mike said, to perform several really important tasks like to know when and where COVID is surging before the numbers tell us that, to better determine which patients are more likely to become profoundly ill, and to provide healthcare systems with risk and severity adjusted information to predict findings. So the tool uses natural language processing and machine learning to scan free-text notes and orders for hundreds of phrases like trouble breathing, or loss of taste, and other free text and discrete data for signs, symptoms, and other indicators of infection. By using this approach, the system is able to rapidly identify patients who are presenting with signs and symptoms of COVID-19.

PP: This is very interesting and of course very timely as well given everything that we are going through today. The tool is essentially an NLP algorithm that mines clinical notes and information in the form of text, and unstructured data essentially sitting inside electronic health records systems. And this is the route that many COVID-19 apps are taking in the context of dealing with the pandemic and having early warning surveillance systems. Jon, can you talk a little bit about how you use this information as a decision support tool not just to flag patients at risk of infection, but in terms of closing the loop? What do you do with that information? What happens next? How do you adjust your care management or treatment and how do you integrate it with your reporting requirements?

JS: We and other health systems are very eager to start using this application. In addition to Geisinger, Atrium, Community Health Network, Advent and I think over 30 other systems are coming online with the application shortly. There are some really valuable ways that health systems can use the information from this application, even above and beyond this important work of syndromic surveillance. I think that systems can identify flare-ups based on health systems’ zip codes. We think often it will be one to four, even more days, before lab test results come back in some instances. In some patients that don’t even get tested or wouldn’t have been tested, usually a week or more before hospitalization based on symptom progression. With this kind of foresight, systems can do things like plan decrease and elective procedures well in advance of being just reactive to public numbers, forecast equipment that an ICU needs based on incidents and even the severity of disease that the tool picks up in the outpatient setting. The tool can also identify patients in the ambulatory setting that are high risk for admission or maybe are more appropriate for a home care environment with home pulse oximetry or other programs. It is important to call out two really powerful features that are coming to the app in the next several weeks. One is that the system will present a pre-test probability based on symptoms to help providers interpret negative diagnostic test results, which we know can be inaccurate, sometimes significantly inaccurate, and both true negatives and false negatives, for that matter. This is where you get to the action at the point of care which Premier always thinks about. The team has also embedded the NIH COVID treatment guidelines right into the CDS tool. I think it’s important to point out that Stanson tool has over 300 hospital system customers. So, this affects and is live and can be live at over two to three hundred thousand providers systems. In this way, with treatment guidelines at the point of care, you can support providers with real-time interventions and to translate evidence into practice, which I think is a core mission for Premier.

PP: One of the things that I read about when I saw the news release on the tool is that it works across different EHR systems. And we all know that interoperability has been a challenge for a long time, it’s getting better, we have got the CMS final ruling that’s going to affect 2021. We are going to see more seamless data flow, but it is still a significant challenge. Can you talk about how do you look across Epic and Cerner as an example or other systems out there? How is this different from other COVID-19 tools that are out there?

JS: Paddy, siloed information and disparity in EHRs across different health systems, not only limits innovation, but in a situation like COVID-19, it’s affecting patients immediately right now. Thankfully, in the last few years we have all seen significant progress in these areas. But this tool, ADAM, which is Advanced Detection Analysis and Management, works well with Epic, Cerner, and I think it’s going to be live over the next couple of weeks or month or two in MEDITECH. As Mike mentioned, the rapidity of getting those solutions live across multiple EHR vendors comes from the fact that the backbone of this solution is Stanson’s PAMA tool that is live at 300 hospitals. So what this then brings is, from growing machine learning standpoint, you’re going to get the combined experience and data of all of these hospital systems across three and now soon to be 40 EHR vendors that will allow powerful improvement of the systems’ machine learning algorithm, not just from one system, but from all of them. This data is never going to be sold to pharma companies and device companies, but there is power in the aggregation of this data. Mike can elaborate, the advanced discussions with several states and parts of the federal government. But important to be clear here, and we know at Geisinger that this data that Stanson and Premier have will never be shared with any outside parties like a state or federal agency without the provider systems written permission, which I think many providers systems, given the mission that we’re trying to accomplish here, would be open to.

MA: The only thing I’d add here is that Premier has taken a pretty significant focus from an advocacy standpoint for interoperability. For all the reasons that Jonathan said, we obviously want the ability to track a patient throughout the progression of the disease, no matter where they’re actually getting care provided. We spent a lot of time working with various datasets to integrate those and work with these EMR vendors, and other vendors to ensure that they have got open data sources. To Jonathan’s point, I do want to sort of make sure to tie this all together from a COVID standpoint. So the reason it’s so meaningful for the states and the feds to sort of step up here and really look at that three-legged stool of controlling the virus is that there is such a high false negative testing depending on when you test versus when you actually get the disease. There were a couple of few articles three weeks ago, one from the Annals of Internal Medicine, the other from the New England Journal of Medicine. They talked about significantly high false negatives. That’s really an issue if you think about somebody’s on their way saying – you don’t have the disease and in fact, you have the disease. Those articles actually presented the fact that the further away you are from being tested when you actually acquire the disease, obviously your false negatives go down. So, you’re waiting, often times, two or three days to get decent results. And what we’re saying is we have the ability to do that real time looking at the symptoms.

PP: I want to dig a little bit deeper into this Stanson tool that you mentioned and how that creates synergies for not just the business, but at the level of the tool itself.

MA: The whole thesis for Stanson, for our investment from a capital standpoint really was, we’re a performance improvement company. We’re all about helping healthcare systems drive improvements from a cost reduction standpoint and a quality and safety improvement standpoint. What we had been doing over the years is obviously taking our best areas or amounts of data in the clinical settings and safety and operations, which is labor and supply chain, integrating those data sets and creating insights into performance improvement for the healthcare delivery systems. And that was great because those insights drove a ton of value. But what Stanson allows us to do is to really create an impression of those improvements. So, Stanson actually writes into the Epic and the Cerner and the Athena EMRs, the appropriate protocols that should be followed that are maximizing high quality, great safety, and low cost. That was the whole initial thesis. We wanted to hardwire those improvements to the point of care into the workflow at the EMR.

PP: It’s all about having the decision support tool at the point of care and being able to act on that. That is kind of the holy grail or the mantra for any kind of decision support tool. You pointedly mentioned that you are very careful about data privacy. I read a study recently, I think it was done by the University of Illinois in Urbana Champagne that looked at some 50 different COVID-19 apps and they were very concerned about the lack of clarity on what is really going to happen to the data. How are you explicitly providing assurances to your patient community that data privacy is going to be maintained, how do you ensure that? How do you execute that? When there are so different people getting access to it?

MA: Premier is an organization that’s been in clinical data analytics, labor data analytics, health information, patient health information for years. So, we have been at it for probably more than twenty-five years. We’ve got a very rigorous and consistent process to ensure that data rights are appropriately being followed. And our ability to deidentify data, we’ve been doing it for years. So, if there is an institution out there that has the ability to do it and has been doing it and that has processes and technologies to do it, it’s us.

JS: Paddy, I think for all of us it’s a fascinating time to think about balancing public health needs and privacy in our own minds and also even what each of us is willing to tolerate in our own personal lives during a worldwide pandemic. As Mike said, the Premier team feels that if it doesn’t have the trust of its partners and their patients, we don’t have anything; and Geisinger certainly feels that way. A lot of the apps that you mentioned are often going to be consumer-facing apps. It’s important to call out for anybody that kind of just dips into the surface of this, that this is not a patient consumer-facing application. This is a robust clinical decision support tool that’s been live for years and has been repurposed and sits with health systems’ EHRs. So what that means, is it sits with extensive BA’s and other agreements that all of Stanton’s existing work is covered by. It’s the type of software and activity covered by HIPAA and has privacy literally protected by law. It’s important to point out that existing syndromic surveillance in our states and country, as I mentioned, involves printing documents, filling some aspects out by hand often, manually keying certain forms, and sometimes even faxing results. That is absolutely a system which is not only not modern but is also insecure from a privacy standpoint. We think that this kind of automated, fully digitized, secured solution to disease surveillance, it leads with privacy and is a significant improvement over the existing model.

PP: What triggers the tool itself since this is more like a surveillance tool. What is the event that triggers this tool?

JS: So, for the informatics wonks there are three, and it started with one and then Stanson came and Geisinger helped and others have worked with Epic and other EHR vendors for the rapid expansion. And I should call out Epic and Cerner. But Geisinger is an Epic shop, so that’s the one I can speak to, has been a tremendous partner here. Understanding that during a national emergency, we need to always move smartly, and we need to move quickly. So, three triggers really fire the tools, ability to take a look and give actionable insights. One is the ordering of an imaging test and of course, in COVID that’s critical and is the backbone of what Stanson’s functionality always was. The other is the order of a COVID test, which is another great place to fire functionality that takes a look at natural language processing on free text and also does analysis on discrete data at the time. And the third is that when COVID test is resulted and the charts opened to analyze the COVID test. That’s a moment when there’s a dip-in and a look-in and Epic’s helped with this, done extensive analysis on the overhang time associated with this. And these are times significantly less than half a second in the hundreds of millisecond time frame.

PP: You mentioned false negatives a couple of times. Have you had a problem with false positives?

JS: Not really. False negatives are the big enemy right now, in terms of what have we seen, how do you validate a tool like this? Early testing that the team has done has found that when we look at symptoms using the methods that we’ve talked about and compare to a later positive PCR viral test, to answer your false positive question, probably about four percent. And so that’s really good but the team’s making it better. I think one really important way to make it better and also to validate it is something that’s ongoing with our health system now, and that’s retrospective cohort evaluation. So, we, and everybody, have months of medical records on patients who later go on to test positive and negative. And folks that do well clinically or unfortunately in some cases do not do well clinically. What we are doing is looking back at a cohort of patients who went on to test positive where they know how they did clinically, and also, a group went on to test negative. So not only does that allow validation but have a very big history in the machine learning and AI area. In fact, we can not only validate the tool there, but also do data driven research to tune and improve the algorithms to significantly increase the sensitivity and specificity of the tool with a known data set and tuning.

PP:: A related question on that, obviously, is evidence. And you are kind of going there at times. Are you building the evidence for this tool as you go along?

JS: Well, some of those initial looks that I mentioned have already occurred and led to that data I mentioned. The other studies that I mentioned, like the retrospective validation and the tuning is happening as we speak, from quality improvement and research perspective, because I do think it is quality improvement work. But as far as the machine learning algorithms tuning is concerned, that’s an ongoing iterative process that’s consistent.

PP: One of the things that has really impressed me is the level of public-private collaboration that COVID-19 has brought about. I have seen many examples at the state-city level. One of my guests on this podcast talked about what they’re doing in the city of Austin for instance. And I see many great examples of how public and private sector are coming together to really address this. Can you talk a little bit about how this tool is being used for public health in general? Let’s say in Geisinger you’re in Pennsylvania, you talked about how this is contributing to public health efforts and especially contact tracing and all that, which is not really a big thing.

JS: There’s a ton of important opportunity in this area. We know that contact tracing, etc., usually falls under local and state health departments, but they’re all spread thin. I think we all saw the study that Ars Technica wrote up that we would actually need three hundred thousand contact tracers to do this job right. Geisinger quickly realized that it’s already expert in managing testing, communicating results, and treating those who test positive. So, Geisinger is performing contact tracing as a public-private partnership and now has twenty-four employees spending significant parts of their workweek on contact tracing. As of a few weeks ago, the team had made over twenty-seven hundred phone calls to follow up on sixteen hundred positive patients. This directly benefits patients, providers, and communities. And how do you take the Stanson tool and actively connect that to states; Mike, I’m sure can elaborate on.

MA: I think at the end of the day, these health officials that we’re having conversations with are trying to really have these decisions from a public health standpoint, be informed by data and science. The idea is if you have what we suggested, which is that three-legged stool of testing and more advanced testing and getting more refined testing and better testing, plus contact tracing, which we always think is going to be something that is going to be debatable. Jonathan made a great comment early on about the debate of positive societal impact versus liberties being sort of tightened. But we do know there are a number of countries that are using iPhones and those kinds of things to track as to where folks have been that have the virus and to be able to alert people that they may have been exposed to the virus. That’s a very meaningful discussion that we need to have and the debate that we need to have in the U.S. around the importance of that. And then finally we have been talking about this syndromic surveillance and the reason it’s so critical is that if you’re the governor of a state, early on, governors of huge states decided to shut the entire state down when maybe there was only a surge in eight, nine percent of all of the counties that represented, 60 or 70 percent of the population. But those other counties were very limitedly impacted. So, all we’re saying is that there is technology and there is data that at the zip code level can provide a great deal of information around how to balance public health versus open the economy, that’s number one. Number two, we have heard a lot of conversation about how this is disproportionately affecting the cultures of color, people of color in the urban settings. Our technology has the ability to identify those issues. And for public health officials to sort of think through what’s the best way to provide capabilities and services to those parts of the population. So, we think there’s a couple of incredibly important use cases that public health officials should leverage for.

PP: Well, John and Mike, it’s been such a pleasure speaking to you. Thank you so much for sharing your thoughts on this. I think this is a very important initiative. And I hope to get you, folks, back again on this podcast maybe a few months down the road when you have more learnings to share from the tool as work on the field and again all the very best.

We hope you enjoyed this podcast. Subscribe to our podcast series at  www.thebigunlock.com  and write to us at  info@thebigunlock.com

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

About our guest

Mike J. Alkire is the President of Premier. As President, Alkire leads the continued integration of Premier’s clinical, financial, supply chain and operational performance improvement offerings helping member hospitals and health systems provide higher quality care at a better cost. He oversees Premier’s quality, safety, labor and supply chain technology apps and data-driven collaboratives allowing alliance members to make decisions based on a combination of healthcare information. These performance improvement offerings access Premier’s comparative database, one of the nation’s largest outcomes databases. Alkire also led Premier’s efforts to address public health and safety issues from the nationwide drug shortage problem, testifying before the U.S. House of Representatives regarding Premier research on shortages and gray market price gouging. This work contributed to the president and Congress taking action to investigate and correct the problem, resulting in two pieces of bipartisan legislation.

Jonathan R. Slotkin is the Vice Chair of Neurosurgery and Associate Chief Medical Informatics Officer at Geisinger. Dr. Slotkin is board certified in neurosurgery by the American Board of Neurological Surgery. His clinical interests include care for back and neck pain, as well as sports-related spine injuries, and he has particular interests in consumerism and the digital transformation of healthcare. His research interests include post spinal cord injury regeneration. Dr. Slotkin has expertise in spine outcomes, caring for degenerative and congenital spine conditions, spinal tumors and spine/spinal cord injury. He earned his medical degree from the University of Maryland, and completed his residency at Harvard University, Brigham and Women's Hospital. He completed his fellowship in spine surgery at New England Baptist Hospital. Dr. Slotkin is director of Spinal Surgery for Geisinger and also serves as associate chief medical informatics officer.

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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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For a frictionless digital consumer experience, healthcare providers and payers must work together.

Posted on by sanjith p

Episode #51

Podcast with Bill Krause, Vice President of Experience Solutions, Change Healthcare

"For a frictionless digital consumer experience, healthcare providers and payers must work together."

paddy Hosted by Paddy Padmanabhan
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In this episode, Bill Krause, Vice President of Experience Solutions at Change Healthcare, talks about removing friction points in healthcare – finding, accessing, and paying for care – throughout the consumer experience journey.

According to Bill, COVID-19 created a big explosion of interest around the role digital can play in the healthcare system. He states that there are several barriers that consumer experiences while accessing care through digital means. To accelerate digital patient experience, healthcare providers must understand the role of payers in a patient’s journey and work together to provide a frictionless digital consumer experience.

Recently, Change Healthcare collaborated with Adobe and Microsoft to launch a connected consumer health suite that enables healthcare providers to create a more streamlined digital health experience throughout the patient journey. Change Healthcare is one of the largest independent healthcare technology companies in the U.S. Take a listen.

Bill Krause, Vice President of Experience Solutions, Change Healthcare in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “For a frictionless digital consumer experience, healthcare providers and payers must work together.”

PP: Hello everyone, welcome back to my podcast. This is Paddy, and it is my privilege and honor to introduce my special guest today, Bill Krause, Vice President and General Manager of the Connected Consumer Experience Practice at Change Healthcare. Bill, thank you for setting aside the time, and welcome to the show. Do you want to spend a couple of minutes talking about Change Healthcare, what does the company do, and what are your focus areas today?

BK: Change Healthcare is one of the largest independent healthcare technology companies in the U.S. We provide a variety of data and analytics-driven solutions and services that focus on clinical, financial, and patient engagement outcomes. We really occupy a unique space in healthcare with our focus on connecting the broad ecosystem. For example, we have deep and broad networks across financial and clinical areas that improve decision making, simplify billing, help with payer and provider processes, payment processing, and generally, help enable better consumer experiences.

PP: On this podcast, we focus mostly on digital transformation. What that means to healthcare enterprises, as well as to the technology provider community that serves the needs of healthcare enterprises. Change Healthcare recently announced a new platform that you have just launched. Can you tell us a little bit about what is the platform called? What kind of marketplace needs you are looking to address with the platform?

BK: Recently, we announced the availability of our connected consumer health suite. The solutions Digital Patient Experience Manager, Shop Book and Pay, Virtual Front Desk, and other capabilities, they really help providers to create more consumer-style digital healthcare experiences. We like to say we are helping providers with this platform power, the connected digital journey for consumers, from internet search through to the exam room. And our focus is around removing as many of the friction points that are typical with today’s healthcare experience across finding care, accessing, and paying for care.

PP: Let us talk a little bit about these suites of solutions that you have launched. In the Shop Book and Pay, you mentioned digital experiences and consumer empowerment and so on. When I look at the digital health solutions landscape, I see that you already have the big electronic health record vendors such as Epic, for instance, and their MyChart platform. And then you have a whole marketplace, called the digital health innovation, an ecosystem of startups that have identified an opportunity relating to any one single touchpoint in the online consumer experience. So, it looks like what you’ve done is taken many of those features, many of those needs, looked for the touchpoints, and kind of aggregated them all into a one-stop platform. Is that a fair way to state that? How exactly would you describe that?

BK: What I would say is our insight and what’s behind the solutions we announced is that what we see as the need is to remove, as I mentioned, like many places where consumers hit barriers in accessing care and using great digital to do that. So really, the analogy is we think about our examples, such as Rocket Mortgage or Carvana, Amazon Go, and others that have taken technology, and to your point, there are existing technologies out there serving different points in the healthcare consumer journey; but the unique insight was bringing these together dramatically, simplifying the process that a consumer goes through really to access the services or products that they need, and to do that in a way that works within the context of healthcare.

PP: So, give me an example of how this would work if I am a healthcare consumer. First of all, would I even be accessing your platform directly, or is your platform kind of sitting underneath maybe a health systems front end portal? How does this work as a consumer, what would the experience look like for me?

BK: There are a number of ways and a number of on-ramps for a consumer to enter this digital journey that we make available for providers. We have partnered with Adobe here and Adobe is a leader in digital experience. As a result of that, we have a variety of capabilities that can really customize the experience to fit the brand and styling and many of the other factors that our provider customers need to really reinforce their strategies. It’s never really been more important now in light of COVID-19 and the dramatic shift towards digital. But most consumers today are really struggling to understand what their financial responsibility is going to be, and their struggles with healthcare. They are struggling to connect together with the steps they need to take. So, a consumer would start the journey, perhaps on the web site of their local provider and they will be able to search for care, understand what care is available to them based on any number of services that are increasingly more shoppable if you will. And by that, we mean where consumers are more actively involved in the decision making around those services. So, they’ll enter through the provider’s web site. They’ll enter into the Shop Book and Pay experience, which is branded for the provider. They’ll locate the provider and the services that they need within their local area. They’ll be able to understand their out of pocket responsibilities, schedule care, and complete the pre-service journey in as simple a way as possible.

PP: And you mentioned Adobe as one of your partners. You also partnered with Microsoft in building the platform. Am I correct?

BK: That’s exactly right. This is bringing together the best of three very complementary companies that are leaders in their respective domain. Bringing together Microsoft’s leadership with cloud hosting and regulated industries and significant capabilities around making it scalable and serviceable across the market. So, one of our objectives here is to make these solutions available for the largest providers, but down to the smallest independent practices as well. And Microsoft has a great role to play in making that scalable. As I mentioned, the role of Adobe and really leading many consumer industries and powering the digital experiences that we all know and love and then change healthcare. And one of the important insights here is in order to make great progress in consumer experience and consumer digital transformation, you have to get access to the workflows and data and other backend systems that are necessary to bridge those silos, if you will. And that’s a great capability that Change Healthcare brings to this partnership on behalf of the customers we serve.

PP: So, staying on the consumer experience for a moment, I imagine that you have your first few clients or deployments already live or in the process of really going life. Can you maybe describe what the architecture looks like? You know, let’s say you’re working with a healthcare provider who is on one of the major electronic health record platforms, Epic or Cerner or one of them. How does your platform fit in that architectural construct? And also, are all the capabilities that you talked about, are they all built native in your platform or do you also have components that are maybe a white-labeled with other startups? How is this whole thing architected? If I look at it from an enterprise standpoint as a healthcare executive.

BK: Certainly. So, it’s architected in a cloud-native structure and with an architecture that allows us to on behalf of our provider customers, to integrate into their systems of record. If you think about just from an overall philosophy and approach standpoint, we view the provider has a number of systems of record that house data needed to support these consumer journeys, be it their electronic medical record or their revenue cycle system. Change Healthcare equips many providers across the industry with some of those systems like revenue cycle management. But those systems of record then interact with the systems of engagement. And that’s really where the Connected Consumer Health Suite plays the role it’s delivering to those providers – a scalable, cloud-hosted architecture that integrates with their data sources and powers for them those digital experiences that they need to support for finding and accessing care.

PP: One last question on the topic. Who pays?

BK: There’s a very simple model to this, which are the customers the providers pay for. And I also want to address another question you asked around third parties as well. But I’ll come back to that. But yeah, it’s a simple subscription model based on consumption that providers pay for and the benefit to them is multifold from operational efficiencies to really and most importantly, attracting and retaining their consumers. And that is really where the value that they receive out of this solution. But back to the other question. We have architected our platform in such a way as to incorporate third parties into the journey. We recognize that healthcare journeys can take many different avenues and providers need the flexibility to be able to accommodate those third parties we’re working with. For example, M.D. Safe, which is a great innovative early-stage company that helps to create a single billing experience for consumers prior to when they need care. So, it just dramatically simplifies what a consumer sees and understands their responsibility to be able to satisfy that responsibility. So, we’ve incorporated that capability into our Shop, Book, and Pay. And we’ve built our architecture and that’s, again, back to the role that Microsoft plays here as well with us and in a very flexible manner. So, it can be extensible over time-based on our customer’s needs.

PP: And it seems to me like the platform you built is one of the early examples that I see in the market of a comprehensive digital consumer experience platform. I see a lot of standalone solutions and one of the big challenges that my clients and all the others that I talk to face is about creating this seamless consumer experience. For the most part, the standalone solutions, they are kind of glued together in a somewhat brittle way and building the seamless consumer experience that we are used to from the Amazons of the world or in our personal banking experiences. Is that a fair statement and how do you think a platform like yours changes that?

PP: That is a fair statement and that’s very much been front and center of our strategy. And really the reason why we’ve partnered with Adobe to utilize the Adobe Experience cloud within this architecture. And our view on this is, again, our customers cannot be locked into perhaps more brittle, single service solutions that don’t allow them to really create and expand on the experiences their customers need. So, if I get underneath the covers of that statement, we’ve made a lot of investment to enable our providers. The use of a content management system that really is world-class and allows for a lot of flexibility. Again, back to customizing, to branding, to be able to create different experiences, to be able to deliver those experiences across any variety of endpoints that consumers will pursue and really bring all of that capability that’s instrumental in a digital experience platform approach, but also campaign management, the analytics to instrument all of the endpoints and engagements so that we can match across the channel and understand consumer behavior and how better to serve it. Again, tying back to the earlier point here, about how to remove frictions. If we don’t have those analytical insights on how consumers are interacting with those digital experiences, then it’s not possible to really effectively remove the friction points and optimize the experience over time.

PP: Yeah, interesting. So, switching to more general topics, what are you seeing in the market in the wake of COVID-19 in terms of acceleration of virtual care models, digital experience related investments in your client communities? Can you talk a little bit about what you’re seeing in the market in general?

BK: Certainly. And I would that there are the near-term imperatives that the market has been responding to, and then there are the medium and longer-term realities that our customers are now positioning themselves to address and all. And what I mean by that is the near-term imperatives, things like enabling virtual care so that patients could be served from that standpoint. I think we’ve all talked about that uptake in the industry, but also things like touchless check-in and minimizing any contact with staff where possible and moving things like forms, paper forms to electronic and delivery, etc. So, there’s been a lot of effort to really identify those gaps in the workflows and really plug those gaps as quickly as possible among our provider base. So that’s the near-term that we see. And I think that’s really true across all different types of providers. And then there’s the medium term, and by medium term I might mean 12 months. You know, for some people, medium is six months or so. But at the end of the day, that medium-term is around reimagining those, the pathways that consumers have got access to care and, how to deliver those digitally. And that ties back to a recognition that any barriers that the health systems or providers can see with regard to enabling easier access to care for their consumers. Those barriers now take a higher priority in terms of where their investment dollars, talent, and resources are going. So, we’re getting a lot of inquiries around consumer experience, strategy, and how to rethink the digital front door. The digital front door concept has expanded beyond perhaps the patient portal to other channels and modalities. So, I think it really created a big explosion of interest around the role digital can play in the healthcare system.

PP: One of the big things that people don’t talk about is that along with this shift to virtual care which has been brought on by a lot of restrictions on people coming into a clinic or a hospital for care. There is a big concern around how to take care of the population in their homes and the chronic care of patients, for instance. And we see that remote care and remote monitoring technologies are also having some sort of a renaissance if you will, or if not a renaissance, maybe accelerating. Is that also happening in what you see, along with improving access to care through virtual modalities?

BK: The short answer is yes. And there are few drivers of that. So, the recognition that increasing scope of care can be delivered in the home setting from the standpoint of now more consumers are being accustomed to that, just given the realities of COVID. But there’s been a growing body of evidence related to shifting care to the home and the value that delivers in terms of benefits to consumer’s quality of life, health outcomes, as well as benefits to the system from an efficiency standpoint. So those drivers as well, I think just continue to encourage that trend. So short answer is yes. We’re seeing that and it goes back to that reevaluation of the predominant models that our provider organizations are really funding and developing. And I think that will continue to play an increasingly large component of how consumers receive care and then how those providers are going to need to retool their system to support that.

PP: What do you see as the one or two big challenges that providers are facing today as they make this transition, as they get ready to accelerate? Because the acceleration of the transformation is kind of inevitable. You either accelerate or you get left behind. What are the one or two big challenges you’re seeing providers struggling with as they try to make this transition?

BK: You know, there’s a few things. One is the organizational capacity to support that transformation. Increasingly, providers are understanding their roadmaps that they want to pursue from a digital transformation standpoint. But the IT departments and teams are just taxed with a number of priorities on a number of fronts. So just that overall transformation burden and fatigue, that’s a reality that the industry faces. I think also, if we play this out a little bit, there’s a dichotomy around how or what maybe good looks like and really a recognition on what is the path forward. So, everybody recognizes the growth of telemedicine is needed and some of the other more tactical areas have to be addressed in the short term. But our industry has a record of adopting many different solutions. And in fact, you know, it’s not healthcare. It’s many consumer industries. But at the end of the day, I’ll come back to those models that were really breakout and drove substantial benefits, were the ones that brought together the journey and really streamlined the consumer journey. So, that’s a different paradigm. So, I think there’s an opportunity and there’s a challenge around that. And the challenge is really what does that look like? And when you start to get underneath that, you realize that a number of the steps in the consumer journey fall on the payer side. So, we can’t forget the payer’s role in this, whether it’s understanding from a consumer standpoint what doctors are in my network, and what are my insurance benefits for particular service, or any number of steps where the consumer is left with a fragmented journey. So, for provider organizations to address this holistically, they have to think about the role of the payer in this and how they can work together.

PP: Interesting. It’s been a real pleasure speaking with you. And I wish you all the best with the launch of your new platform. It sounds very, very interesting, and I will be following what is going on with the progress as you kind of make public statements about it. I look forward to having you back on the podcast, maybe a few months down the road, and maybe you can tell us more about your learnings from the launch of the platform.

BK: Thank you, Paddy. And I really appreciate you having me here today.

We hope you enjoyed this podcast. Subscribe to our podcast series at  www.thebigunlock.com  and write to us at  info@thebigunlock.com

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

About our guest

Bill Krause is the Vice President of Experience Solutions at Change Healthcare. Serving the healthcare industry for over 12 years, Bill leads innovation and solution development for patient experience management at Change Healthcare. In this role, he is responsible for the development and execution of strategies that enable healthcare organizations to realize value through leading-edge consumer engagement capabilities.

Previously, Bill provided insights and direction into new product and service strategies for McKesson and Change Healthcare. He also managed business development planning, partnerships, and corporate development across a variety of healthcare service and technology lines of business for those companies.

Prior to McKesson, Bill worked at McKinsey & Company as a strategy consultant, serving a variety of clients in healthcare and other industries.  He received his MBA from Harvard Business School and his undergraduate degree from University of Virginia. He also served as a lieutenant in the United States Navy.

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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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Post-COVID, virtual care will be about stability, quality of service, and agility.

Posted on by sanjith p
Episode #50

Podcast with Aaron Miri
Chief Information Officer
The University of Texas at Austin, Dell Medical School, and UT Health Austin

"Post-COVID, virtual care will be about stability, quality of service, and agility."

paddy Hosted by Paddy Padmanabhan

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In this landmark 50th episode of our podcast, Aaron Miri discusses contact tracing and UT Health’s contribution to prevent the spread of COVID-19 through their public-private partnership with city of Austin, TX.

Austin Public Health has partnered with Dell Medical School and UT Health Austin to prevent the spread of COVID-19 by doing contact tracing on behalf of the city of Austin. Besides contact tracing, the University is also using emerging forms of healthcare delivery such as symptom checking, COVID-19 drive-through testing stations, home monitoring, and nurse triage to control the spread of the current pandemic. Currently, the medical school has over 200 contact tracers working remotely and have successfully performed one-third of the contact tracing in the city of Austin.

Due to the current COVID situation, healthcare consumers are adopting virtual care technologies that are changing the way healthcare is being delivered today. To ensure smooth delivery of care post-COVID, Aaron discusses how virtual care should be a flawless experience for clinicians and patients.

On data interoperability, Aaron suggests three major areas of focus: Identifying and capturing data for public health; the need for the entire continuum of care to be on some sort of a digital system. According to Aaron, healthcare organizations need full data transparency, governance, and internal communication working together to advance interoperability. Take a listen.

Aaron Miri, Chief Information Officer, The University of Texas at Austin, Dell Medical School, and UT Health Austin in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “Post-COVID, virtual care will be about stability, quality of service, and agility.”

PP: Hello again, everyone, and welcome back to my podcast! This is a special episode, our fiftieth episode of The Big Unlock podcast. It is a real privilege and honor for me to have as my special guest today, Aaron Miri, CIO of the University of Texas at Austin, Dell Medical Center. I am really thrilled to have him join us. Aaron, thank you so much for setting aside the time and welcome to the show.

AM: Thank you very much. Congrats on your fiftieth episode!

PP: Thank you very much. For the benefit of our listeners please tell us a little bit about UT Health Austin and the Dell Medical School and the focus areas for your institution.

AM: UT Health Austin is one of the top global universities in the world. About five or six years ago we decided that we really needed our own medical school, our own teaching institute, our own clinical enterprise, and really help Austin and Travis County in the state of Texas out by bringing out some of the world’s best physicians through Austin. Our goal here has been, number one, first and foremost, putting out the best medical students possible, prepare them to enter residency. Number two, having a clinical practice really grounded around value-based care in the principles of community and community impact. And three, what UT Health Austin is known best for, which is research. How do we do some game-changing research in genomics and sequencing and really take it to the next level? So, it is that every aspect of an academic health care delivery network that you could possibly imagine and then some. And then now, you throw in COVID into the whole situation and it grows even more so.

PP: I know you are a thought leader and you’ve written and spoken extensively about advanced technologies and digital transformation in healthcare. And you are a practitioner of all the same principles in your institution. I want to start by asking you about the acceleration of digital transformation in light of COVID-19. We are seeing that healthcare is going virtual – telehealth and all other forms of virtual care, digital front doors and so on. What are you seeing in your conversations with your peers across the healthcare industry as the high priority initiatives for digital consumer engagement in a post-COVID-19 scenario?

AM: A couple of things. Number one, if you look at it from the CIO’s perspective, it is ensuring smooth delivery of service. So, all the way from the clinician experience, the patient experience, and the entire continuity of care virtually should be flawless. So that there are no hiccups in terms of workflow, orders, medical record, what not. Telehealth experience has been one that we continuously refine, even though now our practice is that majority of it is telehealth, although we’re slowly up ticking the in-person again. So, to the degree of it has been about stability, quality of service, execution, agility. There are new workflows.

I mentioned earlier that we are big believers in value-based care. That’s a team-based approach. So, how do you use a virtual lobby to be able to do a pre-staging of a virtual care team, where you have a social worker, a musculoskeletal worker, and a pain management worker altogether visiting. And then, they are able to meet with the patient as a team. Those kinds of virtual workflows we have been innovating because we are not going to stop our principles, which is, we believe, cohort and value-based care. So that’s from a CIO perspective, making sure that your health systems are able to make that leap and suddenly go from in persons up in the dozens to over the virtual telemedicine into the hundreds, if not thousands of sessions daily. So, you have that component.

From a policy perspective, what we’re seeing is this question mark from the CMS. We even saw last week with Seema Verma stating publicly that it’s her intent or her desire to want to leave a lot of the statutes in place that reimburse at even parity level. So I think as that decision comes out, it’s going to obviously affect the landscape, because if they’re not paying and reimbursing at a level that’s sustainable, our health systems will have to make some tough decisions. Most of my peers I’m speaking with are trying to keep the lights on, making sure that they are able to shake and bake to whatever the requests are coming in and ensuring that their staff, be at their remote or in person, are feeling secure and safe and what not. And so, we’re able to deliver medicine remotely without an issue.

PP: In terms of virtual care, in a post-COVID-19 context, some of the things that I’m seeing through our work in my firm is the emergence of newer forms of healthcare delivery. And a couple that come to mind immediately are contact tracing as an example, and COVID-19 apps in general. Of course, it’s kind of hard to unpack what a COVID-19 app means when there are so many technology providers out there saying they have a COVID-19 app. But then contact tracing is something that is a little more tangible. Could you unpack these things a little bit?What should one be thinking when somebody comes up and says,I have got a COVID-19 app that I can help or a contact tracing app that can help you? How are you going about it?

AM: Let’s talk in generalities now, talking specifically about what we’re doing here with UTH Austin. So in generalities, when I mentioned a COVID-19 app, I applaud the vendor community for trying to pivot, especially a lot of startups out there and say how can we apply our platform, our tech, our algorithms towards something related to COVID-19. The majority of the market seems to be leaning towards temperature indicators, whether your home monitoring for temperature checking, whether you are able to baseline an individual based on questionnaires to say, are you potentially symptomatic. Because you were out on Memorial Day weekend on a lake without a mask around 10000 people and probably at a high-risk to catch COVID-19. A lot of what you are seeing on the market are symptom checkers, home monitoring type platforms, algorithms. I have seen RTLS vendors make a pivot towards trying to say, hey, our Wi-Fi, our TLS system can now track your patients that are positive – where they are and ensure that they are maintaining quarantine procedures, that sort of thing.

What we did here at UT Health Austin is a couple of things. Number one, Austin Public Health asked us to partner with them formally and via that delegation of the public health authority, we were able to do contact tracing on behalf of the city of Austin. So, we stood up an app that does that. We have over 200 or so contact tracers all working remotely, calling into a central call center, and accessing this app that we partnered with a startup based out of Seattle to deploy quickly and robustly. These contact tracers are able to enter any information, such as, where was Aaron? Did Aaron go to the barber? Who was at the barber? Let’s call them. Are they symptomatic, that whole lineage of contact tracing?

Believe it or not, Paddy, contact tracing has been done for quite some time with numerous disease states. COVID is not new but this is the first major disease state I’ve seen a public drive towards. How can we digitize contact tracing? And it’s difficult because the CDC is constantly evolving their data sheets based on what they learn. Obviously, more that we learn from the disease, the more types of data they want, and specificity collected. So, we are constantly having to evolve the product that we put on the market here to help. But I just read some stat last week that we’ve successfully done one third of all the contact tracing for the city of Austin. If you think about the 11th largest city in the country, that’s pretty darn impressive. We did this here at UT Austin on behalf of the city of Austin. So, to the degree that there’s a number of components that go into this, but overall, I’d say from our position here, what we’re doing is number one symptom checking. Number two, we have our drive through COVID-19 testing stations. Number three, we’re doing contact tracing, as I mentioned. Number four, we are doing home monitoring. We’re also doing nurse triage, because a contact could quickly say, hey, I have symptoms, I can’t breathe. We need to triage them so we can escalate into that triage and then immediately either enrolling in-home monitoring if it’s manageable or ask them to be present at the emergency department as soon as possible. So, we’ve been phenomenal at getting in front of this and really wrapping our arms around it and taking it very seriously in partnership with the city because UT Austin has those kinds of resources to bring to practice.

PP: You make a very important point in your comments, which is this emerging public-private partnership, public health agencies partnering either at a state, local, or federal level with the private sector. And we’ve seen some efforts to do that at a national level like Google and Apple have gotten together to develop this API, which they’re making available to the federal health agencies at the national level. Then we’ve seen state-level or city level initiatives where public-private partnerships are getting a handle on this whole contact tracing and controlling the spread of infections. What are the one or two things that are truly important for this kind of a public-private partnership to work effectively to ensure that there is public safety, ensure that there is accuracy in all of the testing and tracing and everything that goes on and that at the end of the day, the desired outcomes are met? What are the one or two things that came out of your experience?

AM: I would say these are the top three things for anybody navigating these hurdles. Number one, full transparency, i.e., partnership at a fundamental level of what are you doing, how are you doing. What are our shared objectives? What are our shared populations that we’re going to focus on? Case in point, UT Austin is really focused on indigent care for the city of Austin, which has been fascinating to learn about. So, making sure that there is transparency, there’s constant communication between myself and my counterpart with the city of Austin, the CIO for the city of Austin, who’s excellent. Our data teams are constantly talking to make sure that the data is being shared appropriately, securely, and that there, again, is full transparency on dashboards that we’re building. And so, the data that we’re putting out and that they ultimately published for the public has validity. That there is data provenance behind it. A lineage that anybody can say – how do you know how many tests you’ve given? So those kinds of things are very important because that’s what takes transparency.

Number two is governance. Making sure that just because somebody wants something doesn’t mean that your two teams and two organizations go out and just do it right. It’s got to have a benefit objective and particularly when you’re dealing with public health, you have to have a hyper-focus on ensuring that these are the objectives laid out by the mayor, by the governor or whatever else as appropriate.

Last but not the least, is internal communication. What has happened with COVID is you have a number of practitioners that are logged in from home using Zoom or whatever. So, we are communicating and having standups routinely with them to understand what the shifting landscapes are, what’s going on here in Austin, and the experience of COVID positive patients walking through the emergency department. Are there new protocols, are there new surveillance problems to stand up based on comorbidity? Is there different demographic that we need to be able to focus on a little differently? We had a discussion this morning on how to if we needed to start monitoring neonates, what would we do? How would we handle that issue? We’re trying to get in front of potential questions that come up.

So those are the kinds of things you need to be doing. There really is that hand-in-hand approach and that there is no one institution blazing down a trail inadvertently because of a lack of communication.

PP: What has been your experience with regards to false positives and false negatives in your application and your program with the city of Austin?

AM: I think the false positives, and what not really stemmed from the types of testing that are available, whether it’s serological, whether it’s swab, whether it’s saliva, and all of those components, I think that the general public is learning more about the accuracy of those various COVID-19 tests. Subsequently, if we get the data back from the lab saying – Aaron is COVID positive, but it was a saliva swab. Looking at the level of validity around that, it has downstream effects. So, as the general public learns more, we’re learning just as fast along with them because we can now have more experience. The world has more experience with COVID-19, and so the CDC modifies their approach on a lot of things as to what’s going to happen there, which affects our day to day planning. But that is really where the rub is then, and it’s not around contact tracing or issues with that. I’m actually impressed with the general public’s willingness to partner. I would say the consensus of folks out there, if you call them and say, hey, Aaron, you may have been exposed when you went to the grocery store over the weekend. Do you recall who you’ve been around the past 48 hours? We haven’t had people like, who would spat out and say, you’re invading my privacy. Generally speaking, people want to help, and people want a partner, and people want to do the right thing. So that’s been really positive.

PP: You mentioned the public’s cooperation in these programs, which is extremely critical for you to get a handle on the spread of the infections. In general, when you talk about virtual care models, going back to the earlier comment that you gave us about digital transformation initiatives, virtualization of care, telehealth models. What are you seeing as the public’s acceptance of those kinds of care delivery modalities, if you will? Are they comfortable with it? Are they happy with it or are they just tolerating it in the short term because there’s no other option? What are you seeing with your population?

AM: What’s important is to understand the population you are trying to serve. So, let me give you a few examples here. One of the populations we take care of, beyond obviously the commercial population, is indigent care, disconnected is another terminology I have heard, using an epidemiology sense. People that maybe do not have access to a smartphone or a stable home or resources to care, they may be live in a food desert. All those social determinants of health type issues. So, we have really had to spend a lot of time to understand that population of the kinds of modalities they do want to engage with. Specific to Austin what we have noticed a few things. Number one, most of the indigent population, English is a second language for them. So how do we put apps in front of them that they feel more comfortable engaging with? In our case, it is predominately Hispanic speaking individuals.

So, we put out a Spanish version of the apps. There is an iOS app, also in Spanish, there is an Android app, also in Spanish. And a responsive web form that’s also in Spanish. This is where they can upload their own contacts, they can do their own home monitoring, they can engage the app. The app lets us know who they’ve talked to, all these kinds of dynamics, which are very important when looking at contact tracing. And then, of course, consent. We spend a lot of time getting consent from people. And that’s explicit consent. So you understand that you were sharing with me, your family members at home and who was around you, and you’re consenting to tell me that you’re giving me permission to go ask those questions on your behalf. I never want people to feel like even though this is a public health crisis, they don’t know what’s going on. And those components of, again, transparency and putting applications of tech in front of people they understand and seeking first to understand have been the acceptance criteria over the general public. And we see most people, because we’re taking the time upfront to do these things, are natural to them. We’re not forcing them to jump through hoops or we’re not forcing them to have to not understand, but yet still share information. People want to help. We have not seen that pushback. So those are important components to understand.

Something I found interesting about the population, a data fact for people out there building apps, is that a lot of the indigent care actually do have a smart device of some sort. They’re just disconnected from the app store. They don’t have a way to download an iOS app or an Android app. Or they don’t have a data plan. They just simply go free Wi-Fi to free Wi-Fi as they walk around the city. So, it is interesting, the other types of connected behavior that we’re seeing, and I think there’s an entire ecosystem at some point that needs to get in front of this. Perhaps this is what you could do now with Elon Musk’s Starlink. He’s putting up with the ubiquitous coverage of Wi-Fi. Those kinds of industries are going to crop up to help connect the disconnected.

PP: We’re doing some work with some health system in New York City. Of course, the population is very similar to what you’re describing, indigent population, but a diverse, ethnically and linguistically. You mentioned the need for multilingual apps, and then you also mentioned that everybody has a smartphone, but they don’t necessarily have access to the app store because they live in either bandwidth deserts or they just cannot afford it or for whatever reason. And so, a related concern that seems to be arising is the notion of inequalities in access to healthcare by virtue of these inequalities in access to bandwidth as an example. Hopefully, all of that will be addressed through initiatives like the one you just talked about, where you’re giving people access to bandwidth so that they can go and download their apps. The apps that they need or being prescribed to them by their physician and so on.

AM: That’s right. And I would also say one more thing is that we have phenomenal teams of clinicians, family medicine docs that are helping us to do all of this. So, they encountered somebody, say, in a food desert. They’ll also set them up with a connection back to local and state resources that help identify may be meals on wheels. Other programs out there that maybe they didn’t have access to or even know about. So, you can use your COVID-19 programs to help populations of people beyond COVID. In our case, we’re giving them resources and access to state resources that they didn’t know existed and say, look, you don’t need to sit there in hunger, or you don’t have electricity. There are ways we can help you navigate these things. It just takes a focus on public health and it takes your team caring, and I’m very proud of the UT Austin team.

PP: Everyone I’ve talked to have come a long way in the last few months. In March, we really didn’t know what hit us and we had to scramble to get things in place. So, that we’re going to take care of the infected population and at the same time make sure that our regular population doesn’t deteriorate in their conditions and so on. I’m going to come to that in a minute. But it also seems to me like over the three or four months, a tremendous amount of knowledge sharing has happened and people are learning from each other’s experiences and really come a long way in terms of understanding how to address a situation like this in future. We’re a long way away from the current crisis itself. We don’t have a vaccine yet and so many other things, but it seems like we’re much more informed today. What has been the kind of collaboration among your peer groups, across your peers, CIOs in other health systems who are doing similar things? Do you have a forum platform where you share ideas, best practices?

AM: There’s been a couple of things. Number one, across all of the UT system – these include all the CIOs of UT South-Western, M.D. Anderson, myself, others – we are all constantly collaborating on what our institutions are doing across the state to take care of Texans and things that we’re learning, whether it’s data, whether it’s processes, whether it’s how do you set up thermal imaging cameras the whole nine yards across. Across CHIME there are numerous discussion boards and information sharing forums where CIOs are talking, there’s a group of about 40 of us that converse via email asking general questions, asking how do you return to work? Thermal camera discussion, like I mentioned, data, data provenance issues, all sorts of things.

At a federal level, I also am a congressionally appointed member of the HITECH. There has been some phenomenal data and idea-sharing exchanges between the CMS, which would just cross all of HHS, and with the payer side and the provider side to understand what is happening boots on the ground and they make modifications. I recall very vividly there was a couple of emergency discussions with HITECH in March and April in which I was very vocal. In couple of Modern Healthcare articles where I stated pretty emphatically that CMS and others needed to help us, they needed to help us immediately. Our cellular lines are getting overrun, there were all kinds of issues. If you recall that timeframe, people thought what was happening in New York was about to happen across the country. And to the credit of HHS, they mobilized.

Whether it’s helping to make sure that data was more quickly, readily available, and normalized, whether it was making sure that CMS was relaxing telemedicine rules as fast as possible. I’m not saying that the HITECH meeting made that all happen. I am saying the right people were listening and they committed to changing it. So, I give a lot of credit to the administration for listening and for making changes that really benefited boots on the ground. So those are the kinds of things that are happening. It is not happening in isolation where you’re sitting at a hospital and you don’t know who to talk to. The whole healthcare community has rallied together to really get behind this. And I haven’t found one person unwilling to help or dive in or lend a hand if you need it.

PP: Yeah, in a way, the pandemic has accelerated the future. And that’s kind of what Ed Marx, my co-author for our upcoming book on Healthcare Digital Transformation pointed out, which is that consumerism and technology are already changing the way healthcare is being delivered and being accessed and experienced. The pandemic has accelerated all of that and by an order of magnitude is what it seems like. Would you agree with that?

AM: I would agree with that. I would also say that consumerization has always been here. The problem with healthcare is that it’s an industry that has always been focused on reimbursement first. And that’s from the early days when Medicare and Medicaid first came out in the mid-60s. That has just become the focus of how do you submit claims for payer reimbursement? And so, because we thought that telemedicine was never reimbursed at a parody level or whatever, that there was never going to be mass adoption, and yet the consumers actually want it. I will give you a specific example. We do net promoter score – scoring for all of our patient encounters on top of age caps and all other things you have to do. We want to know in real-time -How was your experience? Would you recommend a friend? Then, tell us something, in free text form, about your experience that we should know. You usually get the whole, “Aw! Traffic is abysmal on Austin or parking was hard in a garage.”

OK! I’m (Austin) a city. I can’t change the traffic situation. Austin, Texas. I wish I could write for beyond healthcare purposes. However, our NPS was always in the 80s, which is really good looking at the net promoter score. However, since we’ve gone to telemedicine, our net promoter score is now in the 90s. People don’t have to put up with those headaches of traffic and parking anymore. So, consumerization has always been a desire. The problem is the healthcare industry just wasn’t going fast enough for what the general public wants. And so, my hope is now this COVID, as bad as it is, has highlighted the fact that you can be thought blazing with health care and people will adapt to it. They’re not stuck in the 1980s. They want to engage with you via a face time, communication or whatever. They want that. I want that right. I don’t want to drive unless I absolutely have to.

PP: Another topic, the whole notion of data interoperability and how we are set up today versus how we need to be set up for the future. You mentioned CMS finalizing interoperability ruling back in March. And so, we’re going to hopefully see an improvement in data interoperability and all the information blocking practices. But having said all that, the way data is structured today within our primary repository, a system of record, which is the electronic health record. The pandemic has exposed some serious limitations, and this is what I hear everywhere I go. What are your thoughts on that? What should we be doing now from data interoperability and just data management standpoint, knowing that we have what we have, which is a current electronic health record landscape, but our needs are now evolving very, very quickly?

AM: So, without getting overly technical and starting to talk about standards and other formatting and data issues, I will talk about the generalities. Number one, we are still learning about COVID, particularly in public health. We’re still learning what data elements we need to track. This is why the recent issues cropped up about race and ethnicity. And gaps of care, because not everybody mandates those fields to be filled out or we are not capturing it accurately. So, I would say, number one is we need to get a general baseline field for public health criteria. What are the standards that need to be tracked every single time? Is it race and ethnicity and of course, age and comorbidities? What is it? We had the same issue with Zika a few years ago with pregnancy. We weren’t able to track people who were pregnant because pregnancy status at that time was not mandatory. Now it is a required field. So, there are these things we need to learn. I would say, number one, a general baseline of definitions and data capture for public health that everybody must adhere to, rights that standards formation and you could put it through the USCDI process that was developed into 21st Century Cures Act that we did in the HITECH so that we can adopt those criteria.
Number two, I would say that we need to make sure that we do not forget other types of care across the care continuum. Right now, rehab, nursing homes, SNFs, they all need to be on some sort of digital system. They are not, obviously, with the American Recovery and Reinvestment Act of money was allocated towards digitizing the inpatient and acute care market. Not a bad thing. That is where people are the sickest. I totally get it. But we have to go back and make sure those care locations are just as digital and just as regulated as the inpatient facilities are. So, we have a continuum of discrete data.

And number three, a better partnership between public health and private sector. Again, I’m blessed here to be with Austin and UT Austin, which have a great relationship. I do not think the same exists in every locale, in every city. So how do you reboot and have those types of didactic discussions so that in the event of a pandemic, in the case of COVID 19, there’ll be future COVIDs. How do we make sure that those tenants we spoke about earlier are in place of transparency and governance and communication? You’ve got to have all those components working together. It’s not just standards, but that’s how we’re going to advance interoperability. I do think that 21st Century Cures Act, that is the law, as you just mentioned, was finalized, I believe it was beginning in March, should help. But we still have a long way to go because just because I put the tool in front of you doesn’t mean it’s going to be used appropriately.

PP: Well Aaron, we’re coming up to the end of our time here. I had just one last question related to the innovation ecosystem and their role in driving healthcare forward, especially from a digital transformation standpoint. And I know that as part of CHIME, you are also launching a series of webinars related to digital health innovation. What are you trying to address there? What are you seeing in the marketplace and what are you trying to address with this new series? What’s the expectation?

AM: I am a big believer in partnering especially with startups and young companies, on how do you and in a very agile manner, deal with a problem that you’re facing, whether it’s COVID related or not. There are companies out there that are hungry to want to innovate with you, and not that the large companies are bad. We have great partnerships with major companies here, too, at UT Austin. But it’s sometimes a lot easier to partner with a startup and solve a problem. And so, this innovative series that CHIME has started is around that. How do CIOs partner with a startup, a young startup to solve a specific problem? And the session that we have coming up is specific around contact tracing and home monitoring and the whole issue of COVID I just spoke about. When we were faced with this in March, the request comes to you as a CIO. Hey, what do you do for home monitoring on patients? What do we get? How do we build it? Do we build it in Redcap? Do we build an app ourselves? Hey, we need to do contact tracing. We don’t want to do it in Excel. Do we want to build an access database and do some crazy requests? You get like stop. Right. I can do the same old thing over and over again and not really advance the problem. Or I can partner with someone and really knock us out of the world and really benefit the society as a whole, which is the route we went. That’s what this series is about, its about thinking different, stepping outside your comfort zone and feeling OK to break a few rules, because it’s at the end of the day, you have a much more robust delivery of care and care processes. Also, your physicians are a lot happier and your patients, too.

PP: We never really got to talk about remote monitoring, and that’s a whole different maybe another podcast sometime in the next few weeks. Thank you so much for joining us and I look forward to participating in these webinars that you’re doing with CHIME. That is going to be very interesting for those who are listening. I would strongly recommend it. It’s got Aaron moderating them, so it’s got to be an interesting discussion. Well, Aaron, thank you again for joining us and I look forward to being in touch.

AM: I appreciate very much. Thanks, Paddy.

We hope you enjoyed this podcast. Subscribe to our podcast series at  www.thebigunlock.com  and write to us at  info@thebigunlock.com

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

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About our guest

Aaron-Miri-profile

Aaron Miri is the Chief Information Officer for The University of Texas at Austin, Dell Medical School and UT Health Austin. He brings more than a decade of healthcare experience driving growth and innovation, leading both provider and commercial healthcare enterprises, and providing thought leadership and close collaboration with state and federal representatives. As the CIO, Aaron is passionate about humanizing technology by collaborating with clinicians, technology partners, and business champions to truly transform healthcare delivery for consumers, patients, and providers.

In 2018, Aaron was congressionally appointed to the Health and Human Services, federal Health IT Advisory Committee (HITAC), established under the 21st Century Cures Act. Previously, Aaron was federally appointed by HHS Secretary Sylvia Burwell to serve on the HHS Health IT Policy Committee established under the American Recovery and Reinvestment Act of 2009. He is the prior Chair of

the HIMSS National Public Policy Committee and serves as an expert adviser to the United States Senate Committee on Health, Education, Labor, and Pensions (HELP) and to other congressional panels engaged in numerous Health IT policy topics. Aaron also serves as an advisor to the National Academy of Medicine on the topics of healthcare privacy, secure, and data.

Aaron is a well-known international thought leader and he brings a deep understanding of how to leverage digital health and the latest technology to accelerate healthcare delivery across the continuum of care. Prior to joining U.T., he served as the Chief Information Officer for Imprivata, the Healthcare IT security leader, where he helped to build and transform a global commercial enterprise focused on healthcare cyber security. Prior to Imprivata, Aaron was the Chief Information Officer for Walnut Hill Medical Center, lauded by Forbes Magazine as the hospital that Steve Jobs would have built. He has successfully led organizations that achieved the HIMSS Nicholas E. Davies Award, HIMSS Level 6 and HIMSS Level 7 EMRAM status, HITRUST CSF designation, and led the first provider organization to receive the SECURETexas Health Information Privacy and Security certification awarded through the Texas Health Services Authority (THSA). Aaron is also a proud member of the CHIME CIO Boot Camp Faculty and routinely mentors’ early careerists through CHIME, HIMSS and other national associations.

Aaron received his MBA, with honors, from the University of Dallas, and his Bachelor of Science in Management Information Systems from the University of Texas at Arlington. Aaron is a Certified Healthcare Chief Information Officer (CHCIO) through the College of Healthcare Information Management Executives (CHIME), a distinguished Fellow with the Health Information Management Systems Society (HIMSS), and he is a Project Management Professional (PMP) with the Project Management Institute (PMI). Aaron is a nationally recognized 2020 “CIOs to Know” by Beckers Hospital Review and was honored with the 2016 Computerworld Premier 100 Technology Leaders award, 2017 Texas Health IT Leadership Award, and the 2019 Constellation Research Business Transformation 150 award. He serves as a board member in the not-for-profit Cartwheel Health, serves as a CIO board advisor for Dell Inc., and as an advisor for numerous healthcare startups and leading venture capital corporations.

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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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If telehealth is our first peak of digital medicine in COVID, the second will be digital monitoring.

Posted on by sanjith p

Episode #49

Podcast with Ashish Atreja, MD, MPH
Chief Innovation Officer, Medicine
Mount Sinai Health System

"If telehealth is our first peak of digital medicine in COVID, the second will be digital monitoring."

paddy Hosted by Paddy Padmanabhan
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In this episode, Dr. Ashish Atreja, Chief Innovation Officer, Medicine at Mount Sinai Health System discusses how virtual care technologies – remote monitoring, video visits, telehealth, and digital medicine – will bring value to health systems by decreasing cost, increasing efficiency, and improving healthcare outcomes.

Dr. Atreja’s role at Mount Sinai Health System is to enable digital health for value-based and patient-centric healthcare. He states that COVID-19 has been the most significant technology transformation agent in the healthcare industry. According to Dr. Atreja, the next technology after telehealth that will rise out of the current pandemic is digital monitoring.

Dr. Atreja is also the founder of non-profit Network of Digital Medicine (NODE.Health), that promotes evidence-based digital medicine by bringing together a network of societies, foundations, and health system associations to enable digital transformation in healthcare.

Ashish Atreja, MD, MPH, Chief Innovation Officer, Medicine, Mount Sinai Health System in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “If telehealth is our first peak of digital medicine in COVID, the second will be digital monitoring.”

PP: Hello again, everyone, and welcome back to my podcast. This is a Paddy, and it is my great privilege and honor to introduce my special guest today, Dr. Ashish Atreja, Chief Innovation Officer of Mount Sinai Health System in New York. Ashish, can you share a little bit about your role at Mount Sinai and what you are working on today?

AA: Currently, I’m the Chief Innovation Officer in Medicine at Mount Sinai Health System. My goal is to really enable digital health together for value-based healthcare and healthcare efficiency. My foundation was laid in Cleveland Clinic where I did my Residency and Informatics Fellowship. I led on to implement an electronic health record for the hospital. And that got me to innovation bandwagon where I got a chance to go to the first web-based paging application way back in 2006. Really good to see the value in being licensed out and implemented across the clinic health system. And then Sinai hired me for a role where we can combine the best of digital health with the electronic health record to make it a wholesome, patient-centered experience for healthcare. So, it has been just a fascinating journey, learning from everyone in the community, from startups to my partners in NODE.Health and trying to make a difference.

PP: Can you tell us what NOAD.Health is about?

AA: One of the major gaps we see in our ecosystem is there is so much going on in digital health. But who puts it together in terms of saying, these are the best solutions that we have to look for? But really taking a scientific approach to that. So, we created this concept of evidence-based digital medicine or EMDM where we can trust really what is working, what is not working. We create a framework for people to evaluate the technologies because then we feel comfortable in advising and bringing them to the health systems. NODE.Health is a nonprofit network of societies, foundations, and health system associations. It is followed by a consortium of health system leaders and the goal is to first promote evidence for digital health and then enable transformation. We do that through our validation network we have. We also do that through annual conference we have as an education way for people to learn from the case studies and learn from each other.

PP: In my work with health systems today, we see that digital transformation is accelerating and largely as a result of competitive pressures. It seems to me that the focus is primarily today on telehealth and digital consumer engagement. Obviously, because of the high revenue dollars attached to improving access to care. Is that a fair observation? Can you talk of some of Sinai’s digital investments in the near-term and from the longer term as a consequence of the pandemic?

AA: With the COVID phase, COVID has been the biggest transformation agent for us, I would say the progress we saw which would take a few years happened in months. But I think the COVID phase is actually parallel. The transformation technology that has been happening, the access was a big issue and initially, we got it to rise because of the bots. The bots happened to screen patients because we did not have much triage capacity with our personal thing. But then because we had to convert rapidly our in-person visits to video visits, telehealth really become mainstream. I think consumer engagement telehealth became mainstream because of we could not see in person. Post-COVID or the tail of the COVID will take us to a world that is going to persist. If telehealth is our first peak of digital medicine in COVID, I feel the second peak is going to be digital monitoring. Nearly every patient can be monitored through a software or a hardware that will dovetail into a population health approach. That is where I see the biggest gain as well happening from the technologies.

PP: How are the consumers responding to the shift towards telehealth? Are you seeing not just the volumes showing an uptick because that is to be expected, but also the kind of satisfaction levels? Are they happy with the experience, are they going to stay with it when things come back to normal?

AA: My wife is practicing cardiology and she was saying all my patients are coming back as a re-open for the physical thing. And we are going to see a variable pattern. I call it a blended approach. You are going to see some patients who have tasted telemedicine and may not require that heavy physical examination or heavy touch, maybe completely ok with preferring telemedicine. Some people would be equivalent. And some people would still like to come in. I think where it becomes really tougher is now the practice, patients who tasted telemedicine will demand a mixed approach. Some patients will lean towards telemedicine continuation and some will actually go to physical. So, you have to actually take all of those aspects into account. So, it creates an additional layer of complexity than telemedicine only.

PP: In this whole new world, there’s a lot of startup activities that are trying to address opportunities with digital engagement touchpoints in this new virtual care environment. How do you see them holding up from your standpoint? Do you see them pivoting their businesses? Are they staying the course? Are they doing something different? You have a unique perspective by virtue of being the Chief Information Officer. Can you share your observations on that?

AA: I think there are many startups who are suffering if they are in a unique niche area and they are in a research skill or something. And your entire business model was dependent on that. You certainly are in a no man’s zone and don’t know where to go. I have seen many startups evolve and rapidly kind of support virtual care. I can give examples for the Mount Sinai spinout Rx.Health, which I continue to guide. And they have a platform approach to prescribe digital medicine directly from EHR and unify the entire ecosystem. They rapidly extended a partnership and got a whole virtual care tool kit with national societies to support health systems. I think startups, which already have the ecosystem and the infrastructure and the platform, like in case of Rx.Health, it was just adding additional tools to it, will rapidly able to do that and evolve themselves. And that is like one million lives within three months. And startups who are very early are startups who have a unique niche area were struggling. So, we are seeing both patterns, but irrespective we are seeing a pattern where consumer engagement and more than AI engagement really has become pivotal. And patients are able to see what a health system, what a good patient engagement looks like.

PP: In the wake of COVID-19, startups, by definition, they’re meant to be opportunistic. They’re nothing if not opportunistic. One thing that we are seeing is that there’s a lot of emerging opportunity in addressing the immediate needs of the COVID-19 pandemic. And it is a lot of apps, a lot of new solutions, and a lot of existing platforms. They have now either built or launched “COVID-19 applications.” I read a study recently, I think it was done by the University of Illinois in Urbana Champagne, which looked at some 50 different apps, and they raised a lot of questions about the evidence of the effectiveness of some of these tools. They also raise questions about things like the privacy of the consumer data that they are going to access. What do you make of all those that you, as the Chief Information Officer, especially in the NODE.Health? How do you really adjust to all of this? I mean, make recommendations about what tools are going to work and what will not?

AA: I think in terms of COVID, it’s tougher because we don’t have a legacy or a history. We don’t have the time to evaluate. So here you will have to really just see what is happening in real-time and just make some conclusions out of that, which can sometimes be wrong. So, I can take the example of contact tracing apps, which I have been engaged with a lot. And it is just a no-man land right now. This is not like South Korea or China or in some cases India, where you have a government-mandated app that everybody is using. This is free for all and there are so many apps in the market. Most of them are not talking to each other. So, what is the value in terms of public health? There can be value in personal health by guiding. But what is the valid public health space is uncertain. I think what you also have to take into account that you do not have the luxury of evaluating everything. When it comes from a health system perspective my recommendation will be, we look at patterns, look at problem first approach later than what’s out there as a shiny object syndrome. COVID has also accentuated the problem of shiny object syndrome. I think we have to say where your health system is really struggling with. Is it getting new patients into telehealth? Is it as you are reopening getting patients back into surgeries or appointments? Is it your ACO population that is really getting hospitalized a lot? Is it post-discharge care where you are struggling? Or all of that? And then which are other solutions which actually fit into that our platform solutions, which can serve all of them. My recommendation would be to not go with one isolated partner like a point and get solutions. But look at COVID solution as a strategy to evolve post-COVID. So, take the solution that you would really like to evolve and play with post-COVID because it is so much time in security as has been integration and of diligence and other staff. You want to leverage it for the long term, not just for the next six-nine months or so.

PP: Yeah, you mentioned contact tracing. That was the other thing that I was going to talk about. My firm’s been following this, and I’ve been following this. Google and Apple came together and launched the API but then ran into a few challenges because, you know, the public health agencies wanted location data, and they don’t want to share that. So, you know, there is questions about reapplication that wouldn’t be built on top of the API and how effective they’re going to be. Having said all that, despite all of the challenges, it seems to me like some of these new technologies, contact tracing, for instance, have a lot of potential in the future, regardless of whether it is to deal with COVID-19 as a concept, as a theme. Seems like there’s a lot of potential for that. And from my experience, it looks like some health systems are doing their own contact tracing within their own populations in a very limited way. Do think that’s the way to go right now, look at your own population, focus on that, and try to make it work, and then we’ll see about what happens in the broader scheme of things?

AA: I think its elementary. In fact, I’m working closely with MITRE, which is a nonprofit which works with federal agencies a lot, and the presentation was completely focused on we need to have a complementary approach for health systems and public health agencies. And I’m talking with the New Jersey Public Health in New York City as well. And if we just limit the stuff to contact tracing to public health agencies, they don’t have their own patients. So, they’re going to be just putting something out there, but that adoption can be very, very variable. I’ll take the example of Mount Sinai Health System, we launched an initiative called STOP COVID NYC. We were able to reach out to close to one million New Yorkers. Within a few weeks, and we were able to actually digitally monitor 55000 people. I think there’s a value in having five million patients in your network, which you can reach out to and get to engage with them and protect fifty-five thousand employees. So, there’s a lot at stake for health systems and for self-assured employers as well. I do think at least in the U.S. there is more federal approach and data sharing issues and privacy concern, we cannot wait for nine months to actually have a mainstream contact tracing app universally if at all that happens. We have to still look at and within weeks or within days, protect our population and patients.

PP: I think New York is a great example of public-private collaboration, especially in the wake of the COVID-19 crisis and New York is also one of the most heavily impacted areas in the country. Back to the patient experience, consumer experience when it comes to digital engagement. There is no dearth of digital health tools that can solve some problems in the entire patient care continuum, especially in the context of digital engagement. At the same time, I hear all my clients and everyone, they’re saying that they are struggling with creating the seamless experience that people look for and something that you might be used to in an Amazon type of experience or your personal banking experience, for instance. That kind of experience seems to be very, very challenging in healthcare. Why is that? Is that because apps do not talk to one another? Is it because we are not designing them properly? What are your thoughts on that?

AA: I think there are two potential reasons. One is the EHR. The APIs is now opening up. So if that’s your system of record and that’s where your physicians are living, the patients are completely living in a patient-centered world, you have to have an open API to share the data to actually enable that seamless thing. If you can’t have open API, even if it is said they have open APIs and it’s not easy to do that, then you can’t create a customized experience because your record is completely in a proprietary system and you are not able to unlock that. That has been the number one major stumbling block. With FHIR and other standards, I work in FHIR at the scaling committee for ONC FAST Committee, and I think they have in progress. But still daggered what is possible to what is actually a really feasible what people are doing. It like a O gap. The other part is there are differences in operations, whether it’s underserved or not, digital disparities, and also disease-specific differences. Getting a primary care doctor visit is very different than having a surgery done on new for orthopedics, for example, or getting a heart attack or being in a stroke or being in a nursing home. So, the context, the people around you are very different, the length of the time is very different. So, there is enough variability on the patient level, on the system level, on the electronic records level, to be able to orchestrate that in a meaningful fashion and make it universal requires time and effort and investment. And look at the investment Amazon has to make it a seamless thing, people undercount. They just see the expenses here. Hey, let me get it without investing 100 dollars per year and do it, while I am a five-billion-dollar health system. So, I think there is something to be said about investment, but also something to invest in investment, getting things together to make it unified in unison and rather more fragmented.

PP: We’ve had the final interoperability ruling come out in March. And leaving aside the information blocking aspects of it, when we talk about creating these seamless patient experiences, you think that’s going to make a difference? Do you see improvements coming about in the experience directly as a consequence of the ruling?

AA: Yeah, I think that we are going to see a lot more applications, patient-centric applications, leveraging that. And I think we have been waiting for that for a long time. But I think that would become much more mainstream now. There’ll be definitely value. I think the data exchange between EHR’s to EHR’s will still be less. But I think at least the patients will have it, hopefully, and then they can be a whole ecosystem that has to be developed around it.

PP: We’re now in the midst of COVID-19 or somewhere in the journey. But clearly, there is a shift to virtual care and virtual care models of have accelerated, telehealth is mainstream, digital front doors are all the rage, and remote monitoring is gathering steam. We did not talk much about the remote monitoring piece. Do you want to spend a couple of minutes talking about how that is going to change the healthcare experience in the future?

AA: Yeah, I think remote monitoring is probably going to become the dominant way to manage patients. And continuously manage patients. Whether its chronic disease and the reason I am saying that till date the remote mountain has been suffering from two things. One is hardware only play and the patients may not have an easy way to set it up and link to the Wi-Fi. But with 4G devices, which can actually implement hardware, we do not have anything to test or connect makes it very easy. The second was reimbursement for that. So that’s why there’s limited mostly to ACO or post discharge. Now with reimbursement coming from RPM and CCM codes. I think we’re going to see a lot more mainstream implementation of that. I think any chronic disease patient as cardiovascular to others will require digital monitoring. And we are doing it a lot for even many devices which do not have devices by doing software, only digital monitoring. And that is even much more affordable than the hardware on the disk monitoring where you can access patient symptoms and other things to track them and schedules and logic for them. So, I think this combination whether its value-based healthcare, whether it is the readmission reductions, whether it is payer, and then you can automatically set up triage rules or alerting rules to convert those people who are digitally being monitored and can load them into virtual visit or in-person meeting as needed, as we saw with COVID-19. I think we are going to see a lot more push on that and becoming things to scale and getting a lot of value for health systems to decrease the cost, increase efficiency, and improve outcomes.

PP: I think the reimbursement environment is definitely improving, as you mentioned. We saw that for telehealth they made some significant changes and those changes may possibly stay on for the longer term. And we see the same kind of positive momentum on the remote monitoring side as well. So, all that is good news for virtual care models. Well, Ashish it’s been such a pleasure speaking with you. And thank you so much for taking the time to join us and look forward to following all of your work at Sinai and Node.Health and of course, Rx.Health. Thank you again.

AA: It’s been a pleasure, Paddy. Thank you for having me.

We hope you enjoyed this podcast. Subscribe to our podcast series at  www.thebigunlock.com  and write to us at  info@thebigunlock.com

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

About our guest

Dr. Atreja is a healthcare executive with board certification in internal medicine, gastroenterology, and clinical informatics. As the Chief Innovation Officer, Medicine, he leads the Sinai AppLab (http://www.applab.nyc) that is one of the first collaborative hub within academic medical center to build and test disruptive mhealth technologies.

As an intrapreneur, Dr. Atreja has won innovation awards at Cleveland Clinic and Mount Sinai, successfully licensed technologies from academic centers and advises startups, accelerators and Fortune 500 companies in digital medicine. He was first gastroenterologist to get board certified in informatics and one of the first to develop virtual pager and messaging application. Dr. Atreja serves as Scientific Founder for Mount Sinai Spinoff, Rx.Health that brings first enterprise-wide app curation, prescription and engagement platform to risk sharing hospitals and payers in an affordable and scalable manner. Recently, Dr. Atreja established non-profit Network of Digital Medicine (NODE.Health) to connect innovation centers worldwide and share best practices for digital medicine innovation and implementation between industry, payers and health systems. Dr. Atreja is a member of many professional organizations, has published 70 academic papers, presented more than 200 abstracts and has been a keynote speaker globally on topics related to digital medicine evidence and health system transformation. Dr. Atreja was nominated among the Top 40 HealthCare Transformers in the US.

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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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We believe that a business model of payer-provider partnership is best for patients and communities

Posted on by sanjith p

Episode #48

Podcast with Ceci Connolly, President and CEO, Alliance of Community Health Plans

"We believe that a business model of payer-provider partnership is best for patients and communities"

paddy Hosted by Paddy Padmanabhan
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In this episode, Ceci Connolly, President and CEO of Alliance of Community Health Plans discusses the findings of their recent survey on how COVID-19 has shifted consumer behavior towards healthcare and tripled the use of telehealth and other virtual care technologies.

Ceci shows concern about the existing health inequities and hopes that we close the fundamental gap of the digital divide affecting certain sections of the society. She believes that in a post-COVID-19 era, healthcare payers and providers will focus more on virtual care for better patient experience. Ceci further hopes to see virtual care at the core of value-based model in the future.

ACHP is a non-profit organization that brings together innovative health plans and provider groups delivering affordable, community-based, high-quality coverage and care.

Ceci Connolly, President and CEO, Alliance of Community Health Plans in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “We believe that a business model of payer-provider partnership is best for patients and communities”

PP: Welcome back to my podcast and it is my great privilege and honor to introduce my special guest today, Ceci Connolly, President and CEO of the Alliance of Community Health Plans. Ceci, welcome to the show. Would you tell us about the ACHP and your work?

CC: The Alliance of Community Health Plans is a group small but selective group of health plans that are nonprofit, community-based, and aligns with providers. They’re either part of an integrated system or they have these very close partnerships in their communities with physicians and hospitals. We believe that the model of the health plans and the providers being really aligned around the patient and the community makes for a very successful approach in healthcare today. Our work really grows out of that belief and that view that a business model of payer-provider partnership is best for patients and communities. We see better health outcomes, often at a lower cost. Here in Washington, D.C., where we are based, we advocate for that at the federal level, in Congress and in the administration. We also do a lot of work with our clinical innovation department around best practices, shared learning, and research. And we also have a market competitiveness team that looks at that model and really tries to document the great success stories, does a lot of benchmarking, comparative analysis, et cetera. So that is a bit about ACHP and our wonderful members.

PP: What is the size of the members and how many such health plans are there in the country that are closely affiliated with the community health systems?

CC: We have 25 member companies. They range in size from a couple that have enrollment of 100000 covered lives all the way up to Kaiser Permanente with the 11 or 12 million covered lives. We and our members are present in 35 states plus the District of Columbia, representing now about 22 million covered lives.

PP: Your organization recently published an interesting survey on how COVID-19 has shifted consumer attitudes towards healthcare. Would you care to discuss one or two findings? Was there anything that surprised you?

CC: This was a national survey of adults 18 and over across the entire country, a good demographic mix, if you will, to really represent the nation. And we were most interested in the way in which the COVID-19 pandemic has altered patients’ views about going to a doctor’s office or hospital, how they are interested in receiving healthcare services now and in the future. And in many respects, the data validated what we have been hearing anecdotally, but it’s always so powerful to get the data. A very sizable 72 percent of the respondents said that the pandemic had dramatically changed their use of healthcare services over the past few months. What we saw consistently was that through the early months of the crisis and for at least the next three to six months, high levels of anxiety about going to a doctor’s office, a hospital, an urgent care clinic, any of those in-person sites for elective procedures, diagnostic procedures, tests, et cetera. We heard from those individuals who said they had chronic conditions and senior citizens in our survey had even higher levels of reluctance to return to in-person facilities for probably at least the next six months. As you can imagine, that has very important implications for the health sector and potentially large implications for individual’s health. The good news flip side of that is that we saw a remarkable tripling of use of telehealth or virtual care in that time period. And even more impressive was that the satisfaction rate, customer satisfaction with telehealth was just terrific. Of those that had a telehealth experience, whether it was phone or internet in that short time period. Eighty-nine percent said they were satisfied or highly satisfied with the experience. And the individuals in the survey that reported using a smartphone app to manage an existing medical condition might think in terms of diabetes, sleep problems, heart conditions, 97 percent of those individuals describe that as valuable or very valuable.

PP: This is really very interesting data. My firm does a lot of advisory work in this space. So we work with a lot of health systems and help them with their digital health and digital transformation roadmaps. And obviously over the last three months in the wake of the pandemic, telehealth and virtual care models have become front and center in their overall business strategies. The numbers that came out of your survey are just validation for what we’re seeing on the ground. Interestingly, I also saw another survey that was published recently. I think it was by FAIR Health were the increase in total health claims is on the order of 4000 percent over the last one year. And, there are regional differences and some regions are higher and the others are not as high. But you mentioned anxiety. Some of the claims also reflect the fact that there’s a lot of anxiety among patients and were unable to take care of themselves using conventional access to healthcare. So, we are clearly in the middle of a very interesting transition is what it looks like. And I hear that 80 to 90 percent of outpatient care could potentially shift to some kind of a virtual care model. Some of your survey results seem to be indicating that we are headed in the direction. So what are your views on this shift specifically as it relates to access to care for the population served by your member health plans?

CC: I am happy to report that several our members were really in the vanguard of this movement. If you think about UPMC and Pittsburgh or Select Health, which is part of intermountain in Utah or of course, Kaiser Permanente, they have been very early adopters of the technology options and really helped spark ACHP to lobby successfully over a year ago for inclusion of telehealth in Medicare Advantage. And so, we are so pleased to see much of the rest of the world now seeing what we have long seen in terms of the convenience, the lower cost that is available. And I think that the COVID-19 crisis really drew sharp relief as we saw people that otherwise could not get access to medical services, finally could have it with a click of a button on a device. That said, we have also seen that inequities in our society play out in this area as well as so many others today. So, the number of individuals that do not have broadband, that do not have smart devices. Right now, CMS has put in place waivers for audio only services. But there are concerns about whether or not that will hold, especially if it would be factored into what’s known as risk adjustment calculations in the future. So, there are some unknown questions there. We certainly hope that Congress will finally move forward with broadband legislation is one step in terms of closing the digital divide. But there are other things that need to occur, certainly. We are worried that some providers will hurry back to the in-person visits, in part because they have bricks and mortar businesses that rely on the fee for service payments, not just of the visit, but often a lot of additional tests and checks and things that can be run in person, whether critically necessary and appropriate or not. So as much as we see public attitudes moving very quickly and being very pleased with these alternatives, we are not certain yet about the providers. And we know from our own health plans that they really needed to approach this as a partnership with clinicians every step of the way in terms of what areas of care are best suited to virtual versus the ones that are better in person. One of it shouldn’t be a surprise, but many seem surprised that behavioral health or mental health care is specially affective done virtually. These are populations that maybe are not as comfortable out in society at any time, let alone when there is the threat of a corona virus infection. They may have transportation issues or other chronic conditions that make in-person visits challenging. And many of our health plans report that patients sticking to scheduled appointments virtually is higher than the rates that they were seeing pre pandemic in person.

PP: You mentioned the policy environment as a business for telehealth. But there are other aspects of costs that are stranded that come into play when things go back to normal from the patient or the consumer standpoint. There’s also the question of you mentioned it as a digital divide, and especially if we’re underserved populations with broadband connectivity issues and so on. That is the affordability aspect, the transparency to the costs of care or costs of other enablers for cares such as devices. Where do you see all that today and how do you really support your member populations in sort of wading through this thicket of these new tools, technologies, modalities and get the care that they need, but also not find themselves at the receiving end of unexpected costs?

CC: We always try to start with evidence and the wisdom of clinicians when it comes to appropriateness of care. What care being delivered, when, how, where, etc., clinicians talking to their patients. So that is always the starting point for these conversations. As far as the Alliance of Community Health Plans is concerned, we very quickly want to layer on the value discussion. There’s been talk and effort in this country for an awfully long time about moving from our volume based fee-for-service system to a value-based system that rewards outcomes as opposed to just number of procedures, and I would certainly put virtual care into the value-based model approach. And again, clinicians and patients are going to guide much of this. But if a clinician has a diabetic patient, they should be able to think through how much of that can be remote monitoring, emailing, the occasional video check-in. And then when does the patient really need to come in for certain lab work or tests or procedures? So that’s just one tiny little example. But it’s probably going to be a mix. And ideally, you want that clinical team, not just an M.D., but an entire team, to be paid a certain amount of money to care for that diabetic. And they work out sort of the best formula in a value-based arrangement. We have seen that so many of the delivery systems, physician group practices, hospitals, et cetera, that we’re so heavily reliant on volume-driven revenue and fee-for-service that they encountered very severe cash shortages very quickly in the crisis. If you were to talk to clinical teams, physician groups that were in more of the value-based arrangements, they continued to receive those steady payments throughout the crisis. And it meant that they were able to focus on patient care during a crisis as opposed to their revenue stream.

PP: What about price transparency? Do you have any specific thoughts on that, especially as it relates to all the new modalities of care in a predominantly virtual care environment, digital health tools and devices and the like?

CC: We are bullish on price transparency and we have several members that have been far out in front with consumer tools for very personalized price and quality information. I’m thinking about priority health in Michigan and health partners in Minnesota, Presbyterian in New Mexico and many others where a consumer is not only looking up a potential price of a service, but it’s there out of pocket cost and it factors in their own deductible where they are in that deductible. It tells them different locations where they could go and get the service so they can think about travel time and convenience, where if there is a virtual option and many of these tools also marry in quality data so that they can shop for value. And in fact, we are seeing that happening in all the plans that I mentioned. And its terrific news because the patients want to go to those higher value sites and offerings and options, and both the plan and the individual member end up saving dollars. So when you then come over to a policy discussion, what we have put forward for the policy community is a framework for transparency tools that would be along these lines of geared toward the individual consumer where they are with respect to their own coverage options. Where they are located, giving that quality data, et cetera. So, we have put out a framework for certifying an independent certification of those tools. What we are doing over the next several months is inviting many other stakeholders to help us refine this and move it forward in the hopes that we could really offer an innovative, flexible, independent certification as a way to help consumers make their own choices.

PP: The certification presumably will really help consumers kind of navigating their way through all the multiple options that have been offered to them. I want to go back to the point that you made about the digital divide and these are the underserved sections of our population. One topic that keeps coming up in these conversations is social determinants of health. Is your association doing any work in this regard? Could you share any highlights, any of the research that you’ve done or any of the successes that you’ve had in using social determinants of health to better serve your member populations.

CC: It all ties to what our own member companies are doing in their communities. And that is where we learn and identify best practices that we can then share much more broadly. ACHP members have long understood the connection between unmet social needs and disparity in health outcomes. The evidence is very clear. A couple of the areas that our members have really got an out in front. One is around food insecurity and a number had programs dubbed food pharmacy or food as medicine, because the data is overwhelming in terms of your health and nutrition. And it is actually one of the areas in the social needs space where you can have a significant impact in a very short period of time. And I think now with unemployment of 40 million or, so Americans and we are seeing the tragic long lines at the various food pantries that this is so important. So UCare are a member in Wisconsin, which has a significant Somali population and has long also had very culturally appropriate meals, or Geisinger in central Pennsylvania, which not only has the food offering and get your healthy food. But they pair that with things such as cooking classes for individuals to make certain that it’s fun and enjoyable and they know what to do with these vegetables and things that they might be getting. Several of our members are also partnering in their communities around the homeless population. UPMC is a real leader in that and being able to partner with other social service agencies where UPMC comes in and helps to coordinate and manage care for those individuals. So that is another good example. Just since the pandemic specific source out in the Pacific Northwest has turned its entire 20-20 grant-making program to funding healthcare services for the vulnerable populations most impacted by COVID-19, which of course we see across the United States communities of color in particular, that have really in the victims of this awful pandemic. So those are a few of the different very successful approaches that we see in one of our members. And then often we can help to carry it across to others, share it with the policy community, etc.

PP: I am much familiar with the Geisinger example that you talked about, the fresh food pharmacy initiative and how just making fresh food available for populations that are at risk is the ones that have multiple comorbidities and so on. And the evidence is clearly documented. One of my earlier guests on this podcast was the CEO of the Corporate Center of Clinical Relation in Dallas has done something similar with regards to prenatal care and young mothers. Nutrition fresh food has been clearly demonstrated as a factor in improving the health of those populations. What are your members doing today in terms of planning for a post-pandemic era? What kind of long-term shifts are they planning for, especially as it relates to digital health and social care models?

CC: Well, I can tell you they are very committed to the virtual care option for patients, and they are now working to ensure that the areas are good, safe and secure and private guardrails included in all of those communications and that it’s going to sync up nicely with a person’s electronic medical records, that everything is kind of tied together in a coherent fashion for the patient and the clinical team and other technology investments that they may need to expand those services. Working an awful lot with the provider community, especially perhaps some of the specialty areas that might not have had much exposure or experience prior to the outbreak and are really quite hungry for the education and the training and the best practices to continue that. We’re working on the policy level to think through those issues, around reimbursement over the long term and the regulatory environment, hopefully in a value-based setting. We do not believe that it advances health in this country or affordability. If at the end of this crisis we simply have a whole bunch more fee-for-service codes, that will not get us for word in our health care progression. So, we’re very focused on that. Some of the other things are companies are thinking about is their own workforce and more flexibility for their workforces. Of course, they are giving a lot of thought during what will clearly be an economic slowdown, if not recession, for an extended period of time. Growth in Medicaid, growth in the individual market, as well as some number of uninsured. Our plans are focused a great deal on being able to serve those individuals who find themselves in a different coverage situation than maybe they were just a couple of months ago.

PP: Ceci it’s been such a pleasure speaking with you. Thank you so much for joining us. I look forward to following all the great work that the ACHP is doing.

We hope you enjoyed this podcast. Subscribe to our podcast series at www.thebigunlock.com and write to us at info@thebigunlock.com

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

About our guest

Ceci Connolly is President and CEO of the Alliance of Community Health Plans (ACHP), the trade association for nonprofit, community health plans. A prominent voice in healthcare for more than a decade, Connolly has served as a national correspondent for the Washington Post and a leader at international consulting firms, including PwC and McKinsey.

She is coauthor of LANDMARK: The Inside Story of America’s Health Law and What it Means for Us All and has been published in numerous publications, including the New England Journal of Medicine. Connolly was included on Business Insider’s inaugural list of “DC Health Care Power Players” and was also the first non-physician to receive the prestigious Mayo Clinic Plummer Society award for promoting deeper understanding of science and medicine.

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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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In future, 80% of healthcare needs will be addressed by digital health tools.

Posted on by sanjith p

Episode #47

Podcast with Tom White, Founder and CEO, Phynd Technologies

"In future, 80% of healthcare needs will be addressed by digital health tools."

paddy Hosted by Paddy Padmanabhan
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In this episode, Tom White, Founder and CEO of Phynd Technologies discusses why digital front door technologies and interoperability are the key to the healthcare delivery ecosystem. He also talks about the company’s evolution and the marketplace needs they address.

Digital front door technologies are being adopted extensively by healthcare systems and are practical and useful for the industry, especially in the current pandemic situation. Tom believes that 80% of healthcare should be driven through digital means and 20% through phone calls, unlike the current situation.

Phynd Technologies’ platform focuses on the provider data, defined as people, places, and services, and simplifies provider data management for healthcare systems.

Tom White, Founder and CEO, Phynd Technologies in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “In future, 80% of healthcare needs will be addressed by digital health tools.”

PP: Hello, everyone, and welcome back to my podcast. It is my great privilege and honor to introduce my special guest today, Tom White, Founder and CEO of Phynd Technologies. Tom, thank you so much for setting aside time. And welcome to the show.

PP: Tom, could you start by telling us briefly about the company and its evolution and what the marketplace needs you’re trying to address.

TW: Phynd technologies is a little over seven years old. The core thesis that we started with is still the same concept in that we believe that health care systems need a central hub of provider information that can flow into their clinical, marketing, and claims systems that keep everything in sync from a data perspective. But then also enables output into areas that can drive consumer experience and better operations through better provider data. The marketplace need that we focus on was that EHR is fantastic in managing the patient journey, but not designed as much to focus on the providers themselves and providers really defined as people, places, and services. It’s a broad term that means that basically some products, the health care system can offer to the consumer population. So, it literally is the doctors. It’s the locations even nowadays a COVID testing site would be a place to the services that the healthcare system can offer, whether it’s telemedicine, e-visit, virtual visit, those types of things. Historically hospitals manage data on people, places, and services in different places in EHR. From the clinical perspective, marketing typically has its own that drives its patient engagement strategies. Claims have their own system, their own database. What we’ve done is we’ve merged everything into one profile. So, following the Epic model of one patient, one record, we really focus on one provider, one profile, and that profile can be people, places, and services.

PP: You’re right now in the middle of a very exciting time and a transition for healthcare. COVID-19 has accelerated telehealth adoption and virtual care models. So, I imagine that the need for having the ability to go online, triage your own symptoms, find a provider, and schedule an appointment. All of that is coming together in a way that potentially is beneficial for a company like yours. Many health systems are also having financial challenges because of the unexpected costs of COVID-19. How has the market environment changed for you from pre-COVID-19 to now and what does it mean for Phynd in the marketplace now?

TW: Yes, we’ve seen an acceleration in interest from prospects across the country because of the digital front door ecosystem, whether it’s symptom checkers, smart waitlist, appointment reminders, self-scheduling, providers search all these different things. That ecosystem is certainly right now very, very practical and useful. And it’s really being adopted across the industry. What all those systems need is a provider data solution and the central hub idea back to the original question of provider information that people, places, and services that can feed all these different types of systems. Because there’s lots of vendors out there and hospitals, it’s competitive. So, there’s a lot of startups and hospitals are looking at buying different types of solutions. But what they need at the bottom of that is that foundational level is this provider data management platform, the central hub that can keep those. And so, we’re seeing a lot of interest in what we do because it really is that basis for the digital front door. We call it the digital house; we are the foundation for that house. The front door is the web site and the consumer experience. But that notion is going to change and shift as patient engagement tools get adopted. It is maybe the web site for the narrow network that the health systems partnered with. It could be a pop-up microsite on COVID testing tents that are in the city. It could be a payer health care system, the partnership web site really exposed, some value-based care entities, whether it’s ACO, CIM. And so, the notion of a digital front door, we think is going to be expanded to include windows, another door, a front door, back door windows and all those kinds of fun things. The house framework itself is the provider data that’s going to see those different types of systems. And then you have got apps, you’ve got mobile applications, everything’s going to end up being kind of done on your phone anyways.

PP: That’s a very interesting way of looking at the digital front door concept. And I agree with you that there is no single universal definition of digital front doors. That means different things based on the context, based on the entity and so on. And of course, you are obviously approaching it from the point of view of provider data, patient data as the other side of the coin, which is also something that health systems are focusing very heavily on in order to get a unified view of the patients. So, all of this is converging in a way that I think is going to make for some very interesting times for all the companies that are active in this space. And that actually leads me to my next question to you. Where do you see yourself in the context of the entire ecosystem of solution providers that are operating this whole space that for want of a better term, we call the digital front doors? You’ve got the EHR companies – Epic, Cerner, and so on. You have got big tech firms who are trying to have some kind of role play in this. And then, of course, your compatriots in the digital health ecosystem. Where do you see yourself and how do you see yourself kind of maximizing your opportunity in the coming quarters?

TW: So we see ourselves side by side with the EHR, we sit next to Epic or Cerner in that we integrate by directionally where we are the partner with both of them. We have unique applications on provider enrollment with those systems. As the clinical area is engaging with patients, they need provider profiles to actually run the claims and do care coordination, and then that we act as the backbone again the central hub. And so, the provider profile flows from Phynd into the EHR when the patient encounters start. If they’re in the EHR that data is being essentially managed inside Phynd and it’s bidirectional with EHR. So, what’s in Phynd is also in the EHR. If the providers not in the EHR, which happens about 20% times, then we embed ourselves in the EHR workflow so that the registration scheduling folks which are thousands of people in the hospital, can onboard a provider via the EHR that really using the Phynd platform to pull that data and create that provided profile inside the EHR. And then once they’ve created that provider profile in the EHR, its in Phynd. We call it IPASS. It’s integrated. It’s an integrated platform as a service. So again, one to one relationship, then the Phynd application is used across the enterprise. And one of our clients, we have 12000 end users. And these are all staff inside the hospital systems that are changing data on the providers real-time inside Phynd. And then that’s updating Epic as an example or Cerner. But then it’s also going downstream to the marketing team to give them the updates. So, marketing knows what the latest information is and the providers that they’re publishing now on their web site are web sites. And then it pushes down into the claims so when the claim is processed, that the hospital system actually gets paid faster because they have better data in the system on the provider itself.

PP: Are you, therefore, looking to become the single source of truth, if you will, for provider data?

TW: We are the single source of truth is a touchy word. I guess it’s a political word in that, credentialing they manage the privileging in the onboarding of privileged doctors into the hospital. So, they are the source of truth for that process. Whereas from a clinical side, the EHR typically is the source of truths for certain parts of the record of the provider. And then if you look at marketing, marketing is going to have to go to be they’re going to have their own, you know, their own information, whether it’s a bio video, clinical taxonomy, those things, that is a source of truth for marketing. So, we don’t want anybody to think that we’re replacing what they do from a process perspective. But what we do is we integrate all that data into one profile. So, there’s one profile on you, for example, that would have all your clinical information that’s relevant for Epic, all your credentialing information that’s relevant to the credentialing system that the hospital uses. All the marketing data and all the claims data. So, everything’s managed inside one profile. And then what you can do with that because you’ve got it to download one location versus 20 different silos, which is what the way it works now is that you can then point that profile to different things to optimize the operations at the healthcare system. You can make Epic actually work better. You can make marketing have a better search for the providers and scheduling experience for the consumer. And then on the claim side, you can get claims very faster.

PP: Who is your primary target audience within our health system? You mentioned so many different stakeholders. Is it the Chief Marketing Officer, Chief Patient Experience, Chief Medical Officer, who is it?

TW: The CIO is always involved. Some of your past guests on the podcast are clients of ours. Its CIOs, CMIOs, certainly marketing. The marketing officer is heavily involved as well. But in a lot of ways it’s a technology purchase. It’s a data platform that transforms the healthcare enterprise and it can make marketing a lot better. But what is interesting, in the market there is been a lot of vendors for a while that have made marketing-focused solutions. And we think that those were good transitional technologies. But as the pandemic happened and as healthcare systems have focused in on the notion that fewer vendors doing more platform focused concepts like what we do. We think that it makes sense for healthcare systems to really look at things like Phynd and say how can we optimize and operationalize provider data across clinical marketing claims, these different areas versus having these independent systems. So, we end up selling to everybody in a typical environment, we will have a CIO in a room, even CEO, CMIO, Chief Marketing Officer, certainly Chief Digital Officer as well. We have a lot of those clients because we speak their language. We kind of talk to all of them at the same time.

PP: What is your kind of sales cycles look like? I imagine that you have to get multiple stakeholders on board before somebody signs your purchase order, right?

TW: So, it’s certainly enterprise software sales. So, it’s our sales team is a very experienced professional, a consultative team that focuses on the issues and the problems that our clients have. So, the sales cycle could be four months, it could be twelve months to 18 months. It just depends on where the client is. So, I think that it’s just a matter of time that this notion of this digital house, the digital front door certainly has accelerated some conversations we’ve had. The Epic relationship and the EHR relationships are accelerating right now because it’s interesting a lot of our clients when the pandemic happened, they said, we need to bring back retired doctors, nurses and all these folks that we’re not in the day to day health care workplace. They said, how can we find folks that are either retired, maybe taking a sabbatical, those kinds of things. We have all that data. So, it just depends on the event or the opportunity to really say, hey, we really need provider the data front and center in our core IT strategy. Where we are standing up right now is a microsite where one of the biggest clients showed all there COVID testing tents because those testing sites move based on where the hotspots are in their geography. And right now, there’s no way to go for a consumer to go to the web site and say, show me where they are today or where they were yesterday. With Phynd, you can in real-time say, we want to show these 20 or 30 different tent sites and we want to show the hours of operation. And they can change the hours of operation to their web site at a moment’s notice so they can really expand the offering to consumers, just like what you’re used to when you get at Nordstrom’s or any other kind of retail operation that a consumer-focused. We’re helping our clients do that right now. So back to your question. It’s the cycles based on the need in the event of our clients. But we think this universal need for it is just a matter where they all kind of get there and the thought process.

PP: Tom, the digital health ecosystem has been receiving billions in VC money over the last several years. By all indications, it is a thriving ecosystem. A lot of innovative products that are coming out, such as yours. And firstly, I’d love to get your thoughts, on how you’re funded, are you VC funded. Are you in a position to share any of those details just to get a sense of what your profile is, what Phynd’s profile is? And then generally, what do you see as the opportunities and challenges for digital health startups in light of the COVID-19?

TW: We’re VC funded. We have a traditional kind of tier-one VCs. But then we also have some health systems as investors. So Memorial Care based out of Long Beach, California. So, it’s the system that runs from LA down to San Diego. They have an innovation fund. They’re a significant investor in Phynd. The University of North Carolina health care system, they have a venture fund. They’re an investor in Phynd. And so is Orlando Health as well. When we did or our funding, we said let’s blend together both top-notch VS operational experience with top-notch healthcare strategic experience and on the board level. And so every board meeting is really interesting because we get both the VC and put around risk finance, operations and then the healthcare side really driving into things like what we’re experiencing right now in what’s happening to them because we get we kind of get access into what their CEOs and their boards are talking about, triaging their own business over the last couple of months because it’s blocking revenue, because of, elective surgeries and all the things you heard about and talked about. We’re really happy with our mix of investors. Since the pandemic is still a tremendous amount of investment in the patient engagement area. And there’s a lot of great solutions that are out there. And I do think that there needs to be a coming together of them. There’s just going to be too many choices for healthcare systems to have to kind of weed through to buy things. And so, I think that there’s got to be some level setting eventually, whether it’s consolidation, M&A activity, or partnerships as well. But there’s going to be some consolidation. There are just too many vendors kind of chasing some of the same ideas. I think right now and, you know, we help our clients, really. We’re agnostic when it comes to other vendors. And so, we’ll integrate with any of them. But they’re certainly asking us a lot of the questions that you get asked a lot, too, as well. As you know, there are five people that do this one thing. How do we just differentiate?

PP: That’s kind of what we do as a business. We really help our client’s sort through their technology choices when it comes to implementing the digital roadmap. We start by helping them figure out whatever the roadmap even needs to look like for them. And then we go to the technology layer and then the actual partner selection process. But you’re right, that is certainly one of the questions that we get asked a lot, because, there’s so much so little public information about many of the startups. And there’s not a lot of evidence either, especially if you’re a young startup, you don’t have a whole lot of clients and you may have a great product. What are the risks and rewards involved here? How do we manage to all of those become very interesting questions in the context of digital health? These are questions that were never asked. They’re talking to one of the big tech firms. But there’s a whole different set of questions there. Let’s just coming up to the close of our time here. Tom, I just want to get your thoughts on what the emerging healthcare experience looks like for regular consumers like you and me. And what are some of the emerging technologies that you think are going to play a big role in that experience of the future?

TW: I think that’s the future is bright for consumers. When our clients are doing and what my local healthcare system is doing, they have an app that I can message my doctor, my PCP right now. I can do evisits. Those are all great starting points. I do think that they need to get deeper into digital, into the digital diagnosis, that there’s that mystery in science about healthcare, where you think you either have a common cold or you’re really sick. It’s like people tend to be hypochondriacs. I feel really sick when they may not be. And so, this notion that the industry should do a better job of saying, no, no, you can do a digital diagnosis and you’ve got to come call whatever it may be. So kind of really taking some of the mystery out of the diagnosing certain issues. I do think that the digital front door in the technologies will hopefully expand the learning and the use of consumers across the board. There are just too many phone calls, right? I mean, I don’t know your experiences, but I still have to call into my providers sometimes not my PCP, but other providers to schedule, whether it is colonoscopy or whatever, radiologists and. Yeah, and those things need you to know, it needs to flip. I’d say that 80 percent of health care is driven on phone calls and 20 percent digital and needs to be 80 percent digital, 20 percent phone calls.

PP: That’s so well. So, I think that is the headroom for growth. So, if you were half empty or half full, you would look at it differently. But that whole picture there that you just painted. I see that as the opportunity landscape, just inverting that mix going from 80 percent phone calls to 20 percent phone calls. That is the Holy Grail, I imagine. And I hope that we see it in the foreseeable future. And I’m kind of confident companies like yours are going to play an important role in that I guess.

TW: Yeah, I agree with you. I’m a glass half full person in general and I’m just being a startup person. It just kind of comes with the territory. The other point I want to make is that interoperability integration is key. We talked about a tremendous amount of patient engagement vendors that are coming to market in that that you have to be integrated into the IT topography, the landscape. So, the data has to be bidirectional, it has to create this feedback loop. So, if you’re doing digital diagnosis, what are people asking about? What are the conditions? What are the hotspots as far as illnesses? And so, this notion that the digital data feedback loop needs to be there. And so, I just think that’s important for when health systems are looking at vendors that they ensure that it’s bidirectional into their core clinical systems because of the ideas are that of patient care. And so, you just need that data feedback loop.

PP: I generally tend to like startups and especially digital health startups that have a very focused offering and they go deep into it and they do it really, really well, as opposed to a company that might want to do the multiple things and not do any of them really well. I am a half-full kind of guy, I’m an entrepreneur like it comes with the territory. I feel like the digital engagement touchpoint in a typical consumer journey today are not only many, but they’re also expanding. A year ago, you might have thought often, or twelve touchpoints that you would consider high priority focus areas or opportunity areas. Today I can name 25 or 30 such touchpoints. And who knows, a year from now there may be 60 high value, high impact digital touchpoints. And in an ideal situation, you would have a handful of companies that do exceedingly well in one of those touchpoints. And that is what would open up the opportunity landscape for buyers, namely the health systems, in order to really transform the experience of healthcare today. I think part of the challenge also is to your point. A lot of people are pursuing the rainbow, some think that triaging is the cool thing or COVID-19 is a cool thing. But you’ve got to really take a step back and commit yourself to the longer come and pick the sport for you and go deep into it more likely than not to come out successful. But it is a long, hard journey.

TW: Yeah, it’s a journey for sure. And it’s definitely a movement. So, I think that the industry is moving in the right direction, but it’s going to be a long-term process. And it’s going to be great for consumers. So, I’m excited about it. As a consumer of health care on the telephone.

PP: Tom, such a pleasure speaking with you. I look forward to staying in touch and following the progress of finding all the best to you and your team.

We hope you enjoyed this podcast. Subscribe to our podcast series at www.thebigunlock.com and write to us at  info@thebigunlock.com

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

About our guest

Thomas-White

Tom is responsible for day-to-day management decisions and for implementing the company's long and short-term plans.

Prior to Phynd, Tom co-founded healthcare IT company Vocada (now part of Nuance Communications; NASDAQ: NUAN) and Newscast, Inc. He also serves as a mentor to the start-up accelerator Health Wildcatters.

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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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This pandemic is really showing how efficient and useful a video visit can be and it is here to stay

Posted on by sanjith p

Coronavirus conversations

Coronavirus conversations

Seth Hain, Senior VP of R&D and Dr. Sam Butler, Leader of Clinical Informatics at Epic

"This pandemic is really showing how efficient and useful a video visit can be and it is here to stay"

paddy Hosted by Paddy Padmanabhan
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In this episode, Seth Hain and Dr. Sam Butler discuss how emerging technologies like video visits will become an integral part of healthcare in the future and how the current COVID-19 pandemic is proving its effectiveness. They also discuss how health systems are advancing their virtual care technologies in response to the COVID-19 crisis.

Epic observed 2.5 million video visits in April. Seth states that the changes we are seeing in the industry due to telehealth is not only convenient to patients but also preventing exposure of providers and clinicians on the front line. He further states that the effectiveness of technologies, like contact tracing, will be driven by broader adoption and will need to be augmented to fully account for the whole population.

Sam believes that in future physician’s schedule would be 50% face-to-face and 50% non-face-to-face visits through video, telephone, and an asynchronous electronic visit back and forth. He further states that video visits are here to stay and hopes that these visits will be associated with appropriate reimbursements models.

Seth Hain, Senior VP of R&D and Dr. Sam Butler, Leader of Clinical Informatics at Epic in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “This pandemic is really showing how efficient and useful a video visit can be and it is here to stay”

PP: Welcome back to my podcast, this is Paddy and it is my great privilege and honor to introduce my special guest today, Seth Hain and Sam Butler from Epic. We are seeing some very interesting times in healthcare and technologies currently. Telehealth obviously has gone through the roof in the last couple of months and by now that is old news. We also saw one of the leading telemedicine platform companies announced their results and as expected their numbers are off the charts. Are we going to see telehealth visits pull back to lower numbers in a steady state maybe later in the year or we are seeing kind of a permanent shift of certain types of care to telehealth model by default in the future?

SB: I think that we are going to see video visits as an integral part of healthcare from now on. And it took this pandemic to really show how efficient and useful a video visit can be. In my practice, I did pulmonary and critical care before joining Epic and I can remember many times seeing patients in my office, elderly men in a wheelchair with oxygen. For every visit, this patient had to visit IN every three months, a family member would have to get off work, go get grandpa, put him in a car, get their oxygen set up, get him into the clinic, get him into my exam room, which typically needed some furniture rearrangement to fit the oxygen in the wheelchair. All for me to visit with him for 10 minutes. The physical exam was limited in any emphysema patient. There is not much to hear when you listen to their lungs. And I used to think back then, what a waste for the whole system. The family member usually had to take off work to bring the father in. And many times, I could have done that visit as a video visit. But what stood in the way years ago and up until recently was that it was very difficult to get reimbursement for a video visit. In fact, Medicare had this rule that the patient had to go into another healthcare system and sit in an office and then do video between that office and the doctor or you could not get reimbursed. Now, with this pandemic the emergency rules changed, we are allowed to see patients with video visits and bill standard office visits and E&M codes for those visits. We saw 2.5 million visits in April alone and many customers went, we know one customer that went from, thirty-six hundred visits a year to thirty-six hundred visits a day. Video visits are here to stay.

PP: Sam, so you share your specific experience as a pulmonologist, and some use cases have been, for want of a better word, better candidates for tele-visits than others into the recent past. Are we going to see an expansion of the types of use cases for which telehealth is now going to be considered seriously while they were not before, right?

SB: Yeah, it used to be that it was encouraged for you not to do a new evaluation via video visit. And I think from a specialist standpoint, I would have wanted to see that patient with emphysema at least once to get acquainted with him. But the subsequent visits many of them could have been done through video visits. I think other types of complaints and other types of specialties will lend themselves to video visits, things like dermatology and also urging care where you can use questionnaires before the patient comes in. You can say this patient is a perfect visit for a video visit. They are either possibly contagious and you don’t want them to come in the clinic or it’ll be very difficult for them to get into the clinic because of the nature of their illness. For all those things you could do a video visit first. So, I think that the idea that a video visit can’t be used for the initial visit is also in the past.

SH:In addition to the obvious increases that folks are seeing and familiarity that patients and providers are getting with using telehealth platforms, say through MyChart and the changes in billing. We’re also seeing an increase in the number of home monitoring devices that are available. So this is sort of coming on the back of a series of changes in technology that make it more viable as well for that individual to stay in the comfort of their own home and understand things like their pulse ox as part of a visit. Provide that to their provider. Both provides convenience for the patient and in some cases helping not expose the providers and clinicians and folks on the front line as well. So, there’s a variety of positives that we’re seeing start to emerge on top of this.

SB: Now what about the technology to make this happen? I think as we get more home, in-home technology like oximetry and spirometry and even a stethoscope that could be placed on the patient’s chest and to be then listened to or recorded and listened to by a provider, all those are possible. In fact, I recently attended a conference where the discussion was, how do we get more lung function data directly into the EHR and one of the attendees at this workshop was a patient. And he had undergone a lung transplant a few years ago. Every day he does some spirometry, which is he measures his lung function. He does it in a handheld device. And it immediately goes up through his handheld device right into the EHR. And he did that. He said, let me pause during this introduction and blew into the device. And he said, I just sent it to my transplant specialist. So, they will have a very early warning system if he starts to have a problem with his lung.

PP: All these use cases point to a fascinating future in terms of technology-enabled remote care models. In the immediate present, though, with COVID-19 upon us and we’re kind of somewhere in the middle of this crisis. What are you seeing health systems doing in terms of advancing or modifying their clinical care protocols with the virtual care technology, not just telehealth consoles, but other things digital screening you mentioned a couple of uses for remote monitoring?

SB: Many of our customers have enabled and spread quickly pre-visit questionnaires for patients with COVID. So, if you use MyChart, the patient’s portal and say that you’d like to come in and you have a concern about a fever, cough, or shortness of breath. We can direct the patient to ask to a questionnaire. That questionnaire can be easily changed, as recently the CDC added additional symptoms to the presenting symptoms of COVID so we can ask about changes in taste, etc. Those questionnaires then can be answered prior to the visit that can direct when the patient does arrive. The healthcare providers know does this patient need to go directly to an isolation room. Is it best he even stays in the car and somebody comes out and tests them in the car? All those different steps can be done using questionnaires of the patient takes before they arrive and even, they can be used in a handheld device. Eighty-one percent of patients in the United States have a smartphone. But those that don’t can use their computer with an internet browser or even use family members’ or friends’ as long as they have proxy access to their record. And that is the first step.

SH:I think that the underlying platform that organizations are using with the Epic EHR at their core allows them in the context of something like COVID to deploy these tools quite quickly. For example, Cleveland Clinic kind of went from an idea around how to use MyChart care companion to have it deployed in 10 days. And now they are using that in sharing that content across the community, seeing other sites with 15 organizations, using it in another 70 implementing it. And it’s been that kind of core platform that allows those organizations to innovate in that way and then to spread what they learn to other organizations to help all care for their patients more effectively. I think the other interesting piece here is that these tools both help at the point of care in regards to those patients who haven’t been able to fill out their questionnaires at home and provide asynchronous visits, but they also help with public health where we have deeper information and a better understanding of symptoms across the population, for example.

SB: The first part was questionnaires and the second one was the Care Companion. Care Companion is a tool that we use, typically we thought it’d be great for monitoring patients with diabetes and heart failure at home over a protracted period of time. But it is being used for now with COVID to monitor patients with confirmed or presumed COVID infection, monitoring them while they stay at home and doing early detection of symptoms that would indicate they need to come to the hospital. And Cleveland Clinic developed that from zero to in place in 10 days. And then that have spread that to other customers as well. The actual content of the protocol. So, patients can be monitored at home, given daily tasks to monitor their temperature, their oximetry, their symptoms. They have tests to read and become more educated in as they start to feel better, what should they do to keep their family safe for their friends and as they go back out in the community? So, there are educational tasks and then the questionnaires and data that they’re entering are automatically monitored. And if a problem develops like declining oxygen saturation, even before it becomes abnormal, they can be sent to a case manager who can then contact the patient and do one of those video visits we talked about to check with them at home. So, it’s all working together.

PP: I actually really like the idea of co-developing a new solution for an immediate need or even for future needs as an example of Cleveland Clinic and then making it available to the broader community of your clients. One of the things that have been in the news as a collaborative effort among technology companies and between technology companies and health systems is contact tracing. What are your thoughts on this technology as an effective tool for checking the spread of the virus and is Epic doing something in this regard? Are you working on a contact tracing tool?

SH:I alluded a piece of this a moment ago in regard to MyChart functionality and I think broadly looking at contact tracing and possible technology implementations for supplementing it in the community. The effectiveness is really driven by broad adoption. And I think that in the context of some of the technologies that are being discussed today, there are reasonable considerations that might limit that adoption in certain contexts. Both privacy as an example for some of the technologies that track and understand what individuals have come in contact with others as well as limitations in regard to the use of those technologies in certain communities and certain populations. And because of that, we see this as one piece of the puzzle in understanding and tracking the spread of disease across the community and helping understand who may need to self-isolate, for example. But it needs to be augmented with other capabilities, both technology as well as kind of good old-fashioned folks reaching out to others to make sure that they’re taking care of themselves and their loved ones and isolating where appropriate. So, we certainly see it as part of the puzzle, but it needs to be augmented to fully account for the whole population.

SB: I think we are improving some of the functionality of MyChart to allow that. If the patient gives it permission to have like a home screen that says like, I’ve been recently tested, and I am negative. So that can be and allow patients to enter a negative test from an outside source that didn’t come from the health care system.

PP: I think there’s a lot of questions on the privacy aspects of it, but also the effectiveness of the technology. And as Seth spoke about adoption rate in a country like Singapore, where adoption rates are much higher than as a percentage of the population than elsewhere in the world. Still only in less than a million people have downloaded their contact tracing and in a population of four or five million people. So, it’s still not that high. And so, there are limitations even in a closed, tightly monitored economy like Singapore. Interestingly, the emerging job of the zero is contact tracing. So, it’s going to need a lot of people to actually follow through and track down people who potentially may have been infected, as indicated by one of these contractors.

SH:I think in addition to the contact tracing technology is kind of directly around understanding folks coming in contact with one another using smartphones and other devices to allow folks and enable them to track and understand their symptoms COVID flu-like symptoms, for example, and using that to understand it as population level, how things may be spiking or declining as we’re going through this period of social isolation right now. I think that can provide real value in understanding how and when we can start to open things back up.

PP: That’s a great segment. Hospitals are now turning to AI tools to a risk profile patient and predict deterioration, specifically COVID-19. I know Epic has launched a tool to help with this. Do you want to talk about that a little bit?

SH:We’re seeing pretty broad adoption at this point of using our deterioration index model, which aims to predict twelve hours in advance of, say, a code event or need to transfer to an ICU for a patient on the med surge floors. We are seeing that tool used in the context of patients that have tested positive for COVID-19. As this pandemic started to hit we rapidly released a series of capabilities for healthcare organizations to evaluate and understand that model in the context of COVID-19 positive patients, as well as guidance on workflows to use it in that context and it’s been an interesting set of conversations where they have quickly evaluated how the model performs and deeply understood the impact and value of it in workflow and have been implementing it across. We have over 50 organizations using the model at this point.

PP: We focus a lot of the conversation on this podcast also around digital transformation. Now, COVID-19 has happened, as you look across your customer base and when you look across the landscape in general, are you seeing digital transformation slow down, accelerate or remain pretty much the same in light of everything else that is going on with the COVID-19 response?

SH:One of the keys that we have seen is that by having a solid base of both a kind of critical infrastructure and a foundation across the health system, as well as things like MyChart in patients hands, healthcare organizations have been able to rapidly innovate in a variety of spaces, both on the technology front as well as in regards to their operations. So, we’ve talked about some of the technology pieces such as Cleveland clinics, rapid deployment of MyChart Care Companion, the use of the Deterioration index model for COVID the rapid rollouts of telehealth where organizations have changed their practice. But in addition to that, they’ve also updated their operations and continue to roll out in new ways. And we’ve found that particularly interesting to see how they work.

SB: In fact, one of our customers decided to continue their go live as planned before COVID. They were a pediatric hospital and clinic organization, so they were not as affected by the surge or the preparation for such a surge. So, they decided to go ahead and partly they wanted to be up live and ready to go in the fall if influenza, RSV and COVID comes back. And we supported them virtually. So typically, there is a command center set up that go live with many tens, perhaps hundred on how large it is. People in the command center and physicians like myself go onsite to support physicians. And that was all done virtually remotely this time in a virtual command center that we hosted here at Epic with everybody sitting in separate rooms in a single building. And it was wonderful. We were able to give instant support to physicians who were sitting in front of a computer out in California. And our picture would appear, and we could see their screen and answer questions. In fact, it was better than running around the hospital from one floor to another. So, it is changing. And I think implementation meetings, everything is we are doing so much more over webcasts and video ourselves.

PP: That’s amazing. Coming up to the end of our time here. What does a new normal look like once they’re done with all of this?

SB: I think from a physician’s standpoint, I think the new normal will be as Kaiser gave us a preview of that for a couple of years now, 50 percent of their primary care doctors’ visits have been non-face-to-face and that included a smaller amount of video visits. They did a lot more e-visits. But I think the future physician schedule will be 50 percent face-to-face visits and 50 percent non-face-to-face through video, telephone, and an asynchronous electronic visit back and forth. I think that’s going to be the norm and it’ll be associated with appropriate reimbursement so we can continue to do that.

SH:In addition to that, patient and provider approach to new technologies with telehealth, we will see organizations building out and continuing to enhance their foundational platforms to be able to adopt in the workflow. The implications of large datasets using things like the deterioration index model that I described earlier on a new set of patients to help provide better care and get them home quicker to their loved ones. So, I think it is understanding that in the context of, say, rapid changes in the types of patients and the types of illnesses that folks are addressing. These platforms allow them to help rapidly and quickly care for those patients efficiently for seven sets.

PP: Fantastic talking to you folks. And thank you so much for sharing all of your insights. And I hope to talk to folks again sometime in the near future.

We hope you enjoyed this podcast. Subscribe to our podcast series at www.thebigunlock.com and write to us at info@thebigunlock.com

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

About our guest

Seth Hain, Senior Vice President of R&D at Epic, focuses on ambulatory clinical care and the integration of analytics and machine learning into healthcare. During his 15 years at Epic, Seth has also led the system and performance team, with an emphasis in database performance and architecture. A native of Seward, Nebraska, he received a B.S. in Mathematics from the University of Nebraska and an M.S. in Mathematics from the University of Wisconsin. Seth currently resides in Madison, Wisconsin with his wife and two children.

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With eight years of senior-level experience in multi-specialty medical group management, along with fourteen years of clinical practice experience, Dr. Sam Butler brings a wealth of knowledge to his role as leader of Epic’s Clinical Informatics Team, and helps to guide the direction of Epic’s applications. He is heavily involved in the creation and enhancement of features and development of Epic and works extensively to improve physician wellbeing. Sam has a B.S. in Interdisciplinary Science and received his M.D. from the University of Florida.

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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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Digital front door is just the start for digital transformation

Posted on by sanjith p

Episode #38

Podcast with Diana Nole, Chief Executive Officer, Wolters Kluwer Health

"Digital front door is just the start for digital transformation"

paddy Hosted by Paddy Padmanabhan
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In this episode, Diana Nole discusses Wolters Kluwer’s healthcare business and how they are building expert solutions for insights and evidence that are more deeply embedded into clinical workflows. She also discusses how digital transformation is much more than digital front doors.

Wolters Kluwer Health has invested significantly in digitizing their products and offerings over the past few years. They now use advanced technologies such as AI and NLP to enhance their heavily curated content to provide quick and easy-to-find answers for evidence-based clinical decisions. They are also enhancing the delivery of their content with emerging technologies such as voice-recognition. Additionally, they are also improving the user interface by delivering smaller nuggets of curated information customized for individual patients and caregivers. Diana and her team are using voice-enablement to enable clinicians to learn in a setting that’s more interactive and stay updated on the latest practices and clinical knowledge.

Diana believes in evidence-based data to enhance user experience with the latest available technology. Their focus now is on getting patients to engage more, especially those that need stay on very good pathways for their own health.

Wolters Kluwer Health, Chief Executive Officer, Diana Nole in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “Digital front door is just the start for digital transformation”


PP: Can you tell us a little bit about your healthcare business for the benefit of our audiences?

DN: We like to think of ourselves as a very helpful business. Our focus is around making sure every patient has the opportunity to benefit from the best evidence and data. We really focus on what prevents that and what causes variation. We start with education. We have a suite of education tools that continually evolves. As you think about how students get educated today, it’s very different than in the past. But then when they go into practice, as soon as they walk out of the door, they need to keep learning and be updated on what’s the latest practice techniques. As they continue their research and education, we stay with them throughout that. Again, really focusing on what causes breakdowns in clinical care, really caused by variation. So that’s a little bit about who we are and our suite of solutions really tailors towards that.

PP: Would you care to share your thoughts on the final ruling on the interoperability question made recently by the HHS?

DN: I think all of us are trying to digest it as I understand it. I think it’s over like twelve hundred pages. So, we will learn a lot. But I think at the core of this, we really are a supporter of needing to have good strong interoperability without sacrificing any issues relative to privacy or security. So we believe for the long term, if you really want to have the benefits of a digital system and digital ecosystem and be able to support things like AI and its ability to really alter and augment the intelligence that our clinicians need, you have to be able to do this. And we still struggle with that in many cases. And so, the aspect of standards and procedures and interoperability is very important. So, I look forward to, as does my team, really understanding how this may help advance that. I think it’s early days, but certainly we are positive that a ruling has come out and helps to put guidelines for all of us that are kind of working within the system of how to operate best.

PP: Did anything leap out at you when you saw the initial press release, anything at all?

PP: Yeah, I think that the interesting thing is, there’s always been this aspect of who owns the data and whether they have to pay for the data; so they clearly are saying patients should be able to get access to their data without any issues and without having to pay any fees. I think for us working within the ecosystem, it helps to understand how this will actually work as we interface and integrate it into, like the EHR systems. For us the most important thing on our clinical practice side is really how can we do this and how can we do this as quickly and efficiently as possible. So, I think there have been some things written in the document that kind of talks about from a contractual arrangement, things you can and can’t do that would sort of define you being information blocking or not. So, we think that will maybe actually help us in our arrangements with our EHRs. We were very critical and important to us.

PP: What is the current state of maturity of digital transformation as it’s defined broadly in the healthcare ecosystem, in your perspective?

DN: It’s a big question. And obviously you’ll get lots of opinions. But from my perspective, I think we’re beyond sort of the foundation building. I mean, things really are in digital format. We did talk just briefly now about the interoperability issue. We still are plagued by the fact that we can’t probably get data in and out of the system for all the various use cases that could potentially use it. So, I think we’re beyond the foundation building. I do think you’re seeing some nice basic enhancements to experiences on the patient side. You know, there’s pretty basic things, but you can see what your lab results are. You sort of have a place where all of your data is. If you’re in a certain system, you have the ability to do electronic check-ins. We see telemedicine kind of coming up and we’re starting to see some ability to see sort of AI and its application where we have large data sets of labeled things.

I came from the world of radiology. I think there’s a lot of thought that now that we have all of this labeled data, we could apply AI and AI could augment a radiologist role and understanding where there are issues. So, we’re still I would say sort of early on. I think that is really where I think the hope is. If you go back to our focus around variations in care, you still have a lot of handoffs that aren’t managed well within the digital ecosystem. Once the doctor sees the patient and they kind of decide on a treatment path, is it all carried out even out to the patient? I mean, a customer told me, you know, a simple thing is now we can tell whether a patient has actually picked up their medication or not. It’s a simple thing, but obviously goes into a lot of parameters around, OK. They didn’t pick it up. Should we reach out? Can we have a discussion with them? Can we understand what happened? Is it a cost issue? Is it an access issue? What is it?

I think we’re also in that stage where we’re starting to better appreciate what the true connection of digital health could mean for us. And I think that’s still you know, that’s the vision that we’re all kind of working toward. So still in the basics. But, you know, moving through and got a lot of good foundations laid.

PP: In another podcast, the CEO of Wolters Kluwer, Nancy McKinstry, talked about the massive digital transformation that you folks have gone through as a company. Can you share a little bit about what that feels like for your business and share some learnings from that?

DN: Yeah. So, in health, we’ve gone through a similar transformation in our content-oriented business. It’s very heavily curated, just like the rest of our businesses within Wolters Kluwer. And so, the first step was taking everything from what used to be in a printed format and getting in a digital, and 90 percent of all of our solutions now are in digital. We still do have books. People do like hard books and hard journals.

But now, just like we talked about the transformation, the EHR kind of gets everything into digital. We have gotten everything into digital. But now what we’re really focused on is something we referred to as expert solutions and expert solutions or more deeply embedded into the workflow, take into context the use cases of how they’re used. I’ll use as an example UpToDate. We have now gone to something referred to as UpToDate Pathways, and that is more than augmented or guided decision-making tool for specific things that have evidence that’s very strong but wide areas of variation. So, we are really starting to see the move from just taking something that was in print and moving into digital and now moving it into expert solutions. And that’s really where our focus is, where I think we’ll unlock a lot more value and being able to serve exactly the content that our customers need. Having them have to rely on the questions to ask to serve up the content is not the long-term goal. We want to be able to take the patient information from the EHR and provide what we think is most relevant and help them kind of walk through, especially for complex situations. The best way that they could consider a treatment for their patients. So, we also are in a transformation. It’s very exciting, though, because I think that’s really where you see significant impact on patient outcomes if you can do that.

PP: I imagine you use a lot of natural language processing because you’re a content-heavy business in order to curate the content and to get to answers faster than you would through conventional or traditional news. Are you also changing the way you deliver this content?

DN: So, in terms of digitizing it and delivering it in different ways, we’ve been thinking about what’s the interface. We are working on voice because we think voice will be one element of how you might want to get the content and then serving it up. I think what you’ll find is instead of lengthy textual things, you’ll see something either in a curated order or much smaller. We also have, just recently, even in our more patient oriented space, videos that interact with the patient to help them get prepared or help educate them on things that they’re experiencing. We definitely have found in that world we need to have smaller nuggets and to be able to kind of customize it more for the patient and allow them a little bit more flexibility. So, I think you’re right in the fact that the way we serve up the content will be very different, and different types of content, whether it’s video, whether you do it by voice; those things will continue. It’s all about the user experience now and how can you best use the most available technology? So, you hit on a great point there.

PP: Based on what we are seeing, the focus of digital transformation is on digital front doors and the consumer interface.  Do you think that is too narrow and limiting a definition? What are your thoughts on what else health systems should be looking at as we transform the entire system really?

DN: I think the digital front door is just the start. If you use that analogy, there’s so much more in the house that you want to be able to use. I think that we obviously had to have that window and you have to have that be some kind of an enhanced experience. So, people want to open that door. But if you think about it, the type of information I mentioned before, you can now get your lab results. But the lab results, most of us as consumers of that information, we don’t really quite understand what it would be. So if you think about moving more into how are you going to actually manage your health and how do you really get the patients to engage, especially those that really do need to engage and stay on very good pathways for their own health. That’s why we saw so much value and made the investment in the acquisition we did a few years ago. Emmi was really beyond just patient engagement, but it was shared decision making as well as really helping patients as they move into their home healthcare in a transitional environment. So that’s more of how do you stay connected with them? Get things like, register your sugar levels, how is your pain level doing and then how do you really get to understand how that patient wants to interact? And do you see the ability to see when a patient is going into rising risk such that you will outbound and outreach to them to help keep them in their home healthcare environment, which is probably the best situation for them? So, I see it much more oriented towards true engagement with the patient on a much more sophisticated level. But it’s easy to interface with not just the portal, if you will.

PP: You’re kind of at the intersection of education and healthcare. Education itself is going through a dramatic transformation in its own way. What are you seeing there that’s comparable to the kind of transformation the health systems are going through? And how are you enabling that transformation?

DN: Yeah. And it’s really interesting because I called on an academic and I think the professor said people don’t really come to the lectures anymore. And so, it’s sort of indicative of what a student wants, and a student wants to kind of mimic what they’re going to be asked to do outside in the real world. So, we definitely see virtual simulation for things like nursing labs. The interface with the EHRs so they practice within sort of a version of that. But more importantly, what we’ve also done is we’ve integrated technology around adaptive testing where the student can self-test themselves. You can’t game the system. It’s based on AI so it constantly kind of thinks about how you answer something and then serves up additional things. But it really understands if you are getting to the core of clinical judgment. Can you actually understand in these various scenarios how you would react? And we believe and there’s evidence that shows that they’re much more ready. They have higher scores on their high-risk test exams and they really then get out into the world and are ready to go and practice right off the bat.

So, I think that that’s one aspect at the initial education and then the subsequent things, we do a lot of education. We obviously have the ability to do continuing medical education within UpToDate. And then we also have the aspects of our product called Audio Digest, where you can actually continue to learn along the way in a setting that’s more indicative again. Listen in the car, listen while you’re working out, how do you just continue to kind of have those? So, the way people stay updated on the latest practices and how they get their clinical knowledge and judgment at the beginning has definitely changed. It’s much more exciting, I think, as well. Students react much better about getting in and really kind of looking at real life situations.

PP: There is also a component of the infrastructure that is required to support digital front doors and patient engagement and so on. What is your sense of where health systems are, especially as it relates to your solutions? Are the infrastructural components that you expect health systems to have in place and are they ready for what you are providing to them?

DN: Yeah, that’s a really big broad question because I would probably say we all think that there’s still things to invest in. The EHR kind of is the big road, right? The big pipes around the hospital system. But what you’re tending to see, which is typical of where we’re at in the stages, is you see digital solutions popping up. And it’s unclear to us sometimes that as a vendor exactly who will own that. Some of our systems have put in place, like a Digital Health Officer, but we still find that projects and initiatives seem to be owned and influenced in a particular area. And so, will the Chief Nursing Officer still be overly responsible for things that deal with patient experience, patient education, patient interface. I don’t know that we see the need for additional infrastructure to be built. I do think people are still very worried about the aspects of security and privacy and all of those. So, I think that will continue to be an evolving state of affairs.

In terms of the infrastructure, I think most of that is in place. I do also think that you’ll see these naturally have different types of solutions. But ultimately our customers are recognizing that the way a patient is cared for is kind of shifting from various pieces of the solution, like a doctor, a nurse, and a pharmacist to actually seeing the whole ecosystem of the care team. And that’s where we’re trying to work on our own solutions, of how to make sure that we start wherever possible, can populate our solutions with each other’s data. So, as an example, if you’re in UpToDate as a doctor, we do populate drug information and access that we will put Emmi videos in there so you can see what the patient might be prescribed as far as patient engagement. We’re just trying to make the user interface is consistent. So, we are trying to make our own sort of clinical decision support suite look like a suite, act like a suite, have information accessible to it so it can support the movement to the care team approach.

PP: You may have a Chief Digital Officer who is making decisions on certain types of solutions, but then there are other solutions for which functional leaders like the CNIO, for instance, are making the decision. Are you seeing this all converging in some way to some kind of an org model which is becoming a defacto standard like a digital transformation office, for example? Are you seeing that happening? Or do you anticipate that it will continue to be the way it is, which is that decision making will remain fragmented based on the type of solution that people are buying?

DN: We definitely are seeing decisions become more solution, holistic enterprise wide. I think the org models specifically are continuing to evolve. So even when organizations have put in place a Digital Health Officer, they themselves are still getting the lay of the land in terms of how to bring in the right influential clinical people to get to a decision. But we definitely have seen more and more decisions being made sort of enterprise wide, and consolidation sort of more structure around how the decisions are made, which ultimately I think is going to be a very good outcome while not sacrificing any particulars that may need to happen at a particular site. So, I think they’re being very thoughtful about it.

PP: We’re in the middle of the Coronavirus. How is your business coping with the impact and how are you helping your customers cope with the impact?

DN: Yeah. I really do truly hope that we’re more in the middle than it’s still at the beginning. Obviously, we have our own employees that we want to make sure that we have good care around them. And so, we always continue to make sure they’re in a safe environment and have flexibility for them in terms of working from home. In terms of our customers, we’ve made readily available whatever information we have on the situation. We’ve just posted it out there. We’ve posted access for patients. If you as a consumer want to understand what’s real and what’s the facts. We’ve made that available so that we try to put that out there to kind of depict fact versus, you know, maybe not facts.

In terms of our customers obviously, our customers are bearing the biggest burden of all of this right now. And so, we’ve been very flexible. I’ll give you some examples. From a sales call perspective, a support call perspective, if we had planned onsite visits, we’ve automatically called them and said, would you prefer us to just do it virtually. About 50 percent are doing virtual kind of conversations with us right now. And then we have a lot of relationships with societies and many of the societies have had to cancel their conferences. And so, we’re working with them on how we can get there. Very valuable information was going to be presented at those conferences, how can we still get it out? So, we’re kind of working with them on flexibility of trying to still sort of in a virtual environment, get to the objectives that they had for those things. So those are some of the things that we are doing in this current state.

We hope you enjoyed this podcast. Subscribe to our podcast series at www.thebigunlock.com and write to us at info@thebigunluck.com

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

About our guest

Diana Nole is the CEO of Wolters Kluwer Health, a leading global provider of trusted clinical technology and evidence-based solutions that engage clinicians, patients, researchers, students, and the next generation of healthcare providers with advanced clinical decision support, learning and research, and clinical intelligence.

Wolters Kluwer Health solutions support more than 2.5 million clinicians in 187 countries and educate over 1 million medical and nursing students under Diana’s direction. Research and development investments leverage the latest technologies including artificial intelligence to deliver innovative solutions that improve the quality and cost of healthcare, specifically focused on: user experience, decision support, disease detection, advanced workflows, and analytics. Her approach as CEO for Wolters Kluwer is to focus on the customer, drive a sense of urgency, and execute on plans.

Prior to joining Wolters Kluwer Health, Diana served as President of Carestream’s Medical Digital division, a global leader in medical imaging systems. Under Diana’s leadership, the breakthrough wireless x-ray detector, DRX-1, and mobile x-ray solution, DRX-Revolution were introduced and gained market leadership positions. During her tenure, Carestream’s healthcare IT solutions also received “Best in KLAS” designations and the company was chosen as vendor of choice by large, prestigious global healthcare providers across the globe. A nice recognition and acknowledgement by customers that these solutions had a true and meaningful impact. She has held a number of executive positions and is a passionate leader behind many healthcare technology innovations. Her view of the rapid evolution of technology is not one of a challenge but, rather, a chance to unlock new opportunities.

Diana holds an MBA from the William E. Simon Business School and a B.A. degree with Magna Cum Laude honors in Computer Science and Mathematics from the State University of New York. In addition, Diana is currently a Board Trustee of St. John Fisher College, recently appointed their first female Vice Chair, a Board Director of ESL Federal Credit Union, and a Board Director and Chair of the Audit committee of the life sciences company, Clinical Ink.

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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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Digital isn’t just about new care models but enhancing traditional care models through digital means

Posted on by arpita

Episode #37

Podcast with Angela Yochem, EVP, Chief Digital and Technology Officer, Novant Health

"Digital isn’t just about new care models but enhancing traditional care models through digital means"

paddy Hosted by Paddy Padmanabhan
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In this episode, Angela Yochem discusses how Novant Health, a $5.5 billion nonprofit integrated healthcare provider network based in North Carolina, focuses on improving care quality for consumers through advanced technologies. She also discusses her current role and responsibilities at the organization and how digital health is much more than digital front doors.

At Novant Health, digital care is not just about new models of care delivery using digital tools. It is also about enhancing traditional models of care delivery through digital means. Angela, along with her team, provide advanced digital capabilities to improve the quality of care for patients and community members and ensures increased access to care through digital means.

Angela believes that healthcare organizations must adopt contemporary methods and technologies to improve patient engagement and care delivery. However, this opportunity is closing rapidly due to the emergence of unconventional entrants in the healthcare ecosystem. In the podcast, she discusses how she and her team have developed approaches to identify and rapidly onboard innovative digital health solutions for high-impact areas such as stroke care. She advices health systems leaders to bring in people from outside of healthcare for diverse perspectives to solve the most complex problems.

Novant Health, Chief Digital and Technology Officer, Angela Yochem in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “Digital care is about care delivery and enhancing traditional care models through digital means”


PP: Can you tell us a little bit about Novant Health and your role and perhaps also touch upon your unique org structure?

AY: Certainly. Novant Health is a $5.5 billion nonprofit integrated healthcare provider network. We have 15 major hospitals. We have between 650-700 clinics and physicians centers and about 30000 team members. As you can imagine, we’re focused on meeting our consumers’ needs by shaping new services and experiences that resonate with our consumers and the communities that we serve. Technology advances drive a lot of those expectations that our consumers have and certainly change the way we think about engaging with our patients. And, of course, our team members and the border communities. My position was added in late 2017. It was meant to provide a way to increase access to care through digital means and also to define how we can improve the quality of care by leveraging advanced technologies. And, of course, our unprecedented access to data that we enjoy in the healthcare space.

My teams, of course, helped the organization explore many ways that the digital capabilities that we provide can improve the health and the lives of our community members. I’m fortunate that I work for someone I would describe as a digital CEO, Carl Armato. This notion of a digital CEO I think is something that’s so important to so many industries today. Digital CEOs understand that advanced technology functions are essential to providing differentiated services and products regardless of industry and that the executive team for any company must have expertise in the tech field represented at the decision-making table so that they can identify those opportunities when they emerge. In my organization, we moved all of the roles, all of those related roles report to me. And that, of course, helps us reduce fragmentation and avoid conflicting investments or duplicative investments and technology and analytics space across the board. So my senior staff includes a Chief Information Officer, the Chief Technology Officer, our Chief Medical Informatics Officer, our CISO for cybersecurity, our Chief Data Officer and the Chief Digital Health and Engagement Officer, as well as an executive responsible for learning and research across the Digital Partner Services Group, which I believe is a strong, cohesive team of highly talented people from a variety of industries in a variety of backgrounds and credentials area. It’s been incredibly rewarding.

PP: There’s a fairly impressive set up there and we’ll talk about some of the initiatives that you mentioned. Novant Health is based in North Carolina. Is that right?

AY: It is. We’re headquartered in North Carolina. We operate primarily in three states and we have a footprint across five. And I guess what you’d call a super-regional.

PP: Angela, you came from outside the healthcare industry. What struck you the most when you came into healthcare and into this role? What is your assessment of the current state of maturity of digital transformation and digital health in the sector?

AY: Those are two very interesting questions. What struck me when I came here and in fact, one of the reasons I joined Novant Health is that the significance and the importance of the work being done in Novant Health, I mean, literally life and death work, right? Drives a tremendous appetite for adoption of the latest and greatest capabilities that would allow us to provide higher quality care, greater access to care, get better outcomes for our patients and communities. So, it’s that appetite and that ambition for improvement across the board and a passion that I think our team members bring, our clinicians bring at Novant Health that struck me that is so different than what I’ve seen in other industries. I had an opportunity to work with very, very smart, driven, amazing people across the other industries. But the life or death aspect of what it is that we do here just elevated that intensity and I’m the type of person that appreciates that intensity. So that’s one difference that I saw that I really appreciate it.

The other thing I’ll say in response to the second half of your question is that healthcare organizations have an opportunity to adopt more contemporary methods and technologies and architectures and philosophies related to engagement and the delivery of solutions sets to consumers and team members. And I’ll add that the window of opportunity for adopting more contemporary capabilities is closing rapidly. And I would say that based on the number of unconventional entrants that we’re seeing in the healthcare ecosystem.

PP: Defining digital health in terms of just digital front doors, is that too limiting? Should we be thinking about modernizing technology to your comment about bringing in contemporary technology and therefore expanding the scope of digital transformation? How are you defining digital transformation in your role?

AY: This is a fantastic point that you raise. Thinking about digital front doors and only that as being the scope of digital engagement is of course very, very narrow. At Novant Health, we define digital care in both the ways in which we use digital channels to offer care, which is what you’ve just described, but also in the ways in which we enhance our traditional models of care delivery through digital means. You see a lot of investment across the investor community in point solutions that are allowing us to provide as we adopt them. Unprecedented access to care using devices such as our on-demand TytoCare visits or, the ICU capability, tele-behavioral health, kiosks, and remote locations, community centers, and schools. All of these sorts of things are highly visible and they’re absolutely a real thing and a real focus area for us as well as for everybody else.

But to your point, we also focus very relentlessly on capabilities that increase the quality of care. I’ll give you a couple of examples. Earlier in 2019, we launched across all of our hospitals a stroke care solution. I’m sure that your listeners know what happens when a patient exhibiting stroke symptoms shows up in emergency department. But just for those who don’t, I will describe it very briefly. A stroke patient shows up, an emergency department whisks them back, puts them in a CT scanner. They get into a CT scanner, CT scanner runs. And then once the scan is complete, the images examined by the radiologist on call, who in turn might pass it along and see something that may need some care, some attention, will then pass along to the physician on call who then engages the neurosurgeon on call and somebody at some point ready for the operating room. And if there’s some sort of operable occlusion, the patient is treated in that operating room. My understanding is that the national average is somewhere in the mid-50s of minutes. So, between the time when the patient shows up to the time when the operation is being conducted, and if you think about a stroke patient losing a couple of million brain cells a minute, give or take, that’s a lot of minutes. It’s a lot of brain cells lost. So, we have partnered with a third party called Viz.aI who receives the CT scan data while the scan is still being conducted. So as soon as the patient goes into the CT scanner, in any of our hospitals, we stream the data into the Viz.aI environment and they apply AI-based algorithms to the streaming data as it comes through and they can identify an operable occlusion if it exists well before the scan is complete. And so, their solution actually sends the scan to the neurosurgeon on call and makes a notification to the OR so that we have treated patients in as few as 14 minutes from the time they show up to go and see department exhibiting stroke symptoms. Big deal. Our average amount of time with this AI solution in place is about somewhere between 22 and 25 minutes. Well below the national average.

Now coming back to an important point, between the time when we learned of the existence of this type of solution and the time we had it in all of our hospitals, its four months. So, it’s not just about adopting solutions that are truly life changing, life saving for our patients. Increasing the quality of care in this example in the stroke protocol. It’s also about preparing the environment so that you can adopt rapidly these sorts of solutions without the traditional sort of year-long analysis phase that might go on otherwise.

PP: Can you share any early learning, any data points that could benefit our listeners and all those who are implementing these kinds of tools for improving patient engagement?

AY: Absolutely. One of the things that was so interesting when we launched this digital health and engagement division, which is led by a practicing family physician and a strong team of people from a variety of backgrounds, is that the appetite in our patient community is so strong for helping us as we develop these solutions. Our strategy for everything we do at Novant Health starts with the patient. We want to know how we can eliminate their pain points, what do they need, how can we change to meet those needs, and so on. So, when we announced the creation of this division, we ended up having 7500 patients sign up to be members of this group we call ‘community voice’. So, this is a group of patients, community members, and caregivers who’ve agreed to be our focus group and sometimes a pilot group for new digital capability.

So, the learning that I would pass along to others is the appetite exists. And you can have a very, very large sample set of participants as you run experiments with new ways of engaging your patients digitally. I think you have to figure out how you’re going to manage that community, which we’ve done and obviously which can be done. It’s been a wonderful success. And the most recent example I’ll give you is our exclusive partnership with a company called TytoCare.

So, it’s just soft launched in North Carolina and it’s for On-Demand remote medical exam. We’ve had On-Demand video visits forever. TytoCare is a device that’s about the size of the palm of your hand and it has a variety of peripherals that plug into it. And these devices, when used by patients or caregivers, allow them to connect with a Novant Health provider who can virtually examine the heartbeat, the lungs, look at the breathing, look at the skin, look in the ears, look down the throat, look in the eyes, look at the nose, check the abdomen and so on, from wherever they are. And all of these examinations are not only being guided by remote provider but in the case where a patient might want to do the self-exam without a provider live, then the device itself will guide the patient through the process, analyzing the signals coming in from the advanced sensors and the device in real-time and using those signals to tell the patient how to adjust the device.

For example, if your patient is trying to capture a picture of his or her own eardrum, then the device will guide the patient until the image of the eardrums is collected and then it’s automatically, immediately saved in the electronic health record for that patient. So, a really interesting advancement in providing access to care. For anybody who’s ever had a child who suffers from multiple ear infections, if you can imagine, 10:30 at night your child exhibiting ear infection symptoms, wouldn’t it be great not to have to worry about taking off work the next day and trying to get the child an appointment and instead allowing an exam to happen right then, having the ear infection diagnosed right then and having the prescription called in right then and the child gets to start taking the treatment immediately before even going to bed that night. So, this is the sort of thing that the team is working on and doing some fairly groundbreaking work in our region.

PP: You’ve had great success in having your patients engage with the digital tools that you’re putting out and have thousands of patients sign up and be a part of it, willing to participate. Now you’ve got a self-triaging kind of a tool through the TytoCare device. So, it seems like that is a recurring theme that you’re getting patients engaged in their own care instead of having to push it out to them. And you’re getting a fair amount of success in the virtualizing care through advanced technologies. Am I getting it right? Would you agree with that assessment?

AY: I do agree with that assessment, but it’s a journey that goes on constantly. So, this is not a space in which we can rest on laurels. This is not a space that remains stagnant by any stretch. We have to continue to adjust to emerging patient expectations, the needs of our communities as they evolve. And those are the sorts of things that I think keep us on our toes. And that’s why we built these constructs that allow us to continually look for these opportunities and run experiments with some of the technologies so that we understand what the impacts would be and how to prioritize the work.

PP: Can you talk a little bit about what your goals are for the Institute of Innovation and AI and how you are harnessing data to drive these improved experiences? Talk a little bit about the institute itself and the goals, if you could.

AY: Sure. So, we launched the institute this past year. I co-founded it with Dr. Eric Eskioglu, who is our Chief Medical Officer. He happens to be a practicing neurosurgeon and before he was in medicine, before going to medical school, he was actually an aerospace engineer. So, he’s a rocket scientist. So really great partner to have as we think about things related to innovation and artificial intelligence and other advanced technologies that really need never be explained to him. He’s always there as a tremendous partner with me, as a digital leader. So, when we launched the institute, the goal was to identify these technologies that may not even be commercially available? How do we use them to accelerate solutions that allow us to provide the highest quality, highly personalized care.

The constructs allow us to work with our very engaged physician community, as well as other team members from across the system and partner very easily with a variety of third-party types. We partner with members of the startup community. We partner with universities and other research organizations, other healthcare organizations. A variety of unconventional partnerships tend to be crafted as part of the work that we do inside of the institute. And ultimately, this allows us to run rapid experiments with new solutions that understand impact based on real data that we can collect, not just, suppositions, better engage the broader community inside of Novant Health to get involved in making these game-changing advances for our patients and in our practices and also to best manage investment so that we’re not a naturally fragmented in the sorts of experiments that we run across the board. It’s been a great success in the sense that we’re able to do the work rapidly and with a feeling of having the right experts in the room at the right time.

PP: Can you give us the State of the Union on data interoperability and how are you really harnessing all the emerging datasets that we’ve talked about? We tend to talk a lot about EHR data, but there’s so many other emerging data sets. How are you actually harnessing the data for all the insights that you can potentially generate or some of your programs? Can you talk about that?

AY: Let’s break this down a little bit. So when we think about the broader state that we manage, what are our assets? What do we bring to the solutions that we define for the toughest problems that we’re facing in healthcare? Data is one of those assets. We have patient clinical data. We have consumer data. We have behavioral and trend data. We have our business’ master data. We have a variety of data from many, many sources. We have to have a place where the data can reside and we can apply functional capability to it.

Functional capability is expressed through a variety of solution sets. Some are homegrown, others are provided by various third parties. As we’ve discussed already, we have digital assets that provide care and other access related capabilities to our patients and our communities. We have capabilities that support the running of our business and other foundational elements. Many of these capabilities can and should be provided by a traditional healthcare vendor like an EHR vendor. It is about about data. It’s best for us to focus on creating an architecture that can allow for interoperability between solution sets and various third parties in a highly secure fashion. That’s how we get the most out of the unprecedented access to data that we have. This is what’s going to allow for rapid adoption of potentially differentiating services for our patients. This is what leads to that extreme personalization in all engagements with patients improving the quality of their care through faster diagnosis, breadth of treatment options and of course all the other advanced tech that we can apply to it.

With such extraordinary availability of data and the things that we know we can do within the existing constraints, and within our existing agreements that we have that patients for the usage of the data. We are watching with great interest this debate and the deliberations that are ongoing. And while I don’t have direct visibility into how those considerations are playing out, my hope is that the eventual ruling will benefit our patients. And meanwhile, the things that I can control are the architectural choices that I just mentioned. As long as I stand ready to be as interoperable as possible and as secure as possible across the board, then whatever the decision is, we will be best positioned to serve the patients and communities.

PP: Digital programs, in general, are in early stages of maturity and there’s a long way to go to your point earlier that it is a journey that is by no stretch it’s all done kind of thing. So how do you actually keep track? How do you measure progress? How do you keep score of whether a program is working or not?

Well, so we look at outcomes fairly consistently across the board. So, we measure the quality of our care through a variety of mechanisms. We measure the access to care, the ability that patients have to access care at Novant Health. We in the digital channel space have all of the usual measures that other industries have been using for engagement, for digital engagement, and we certainly track that because we are a business and we’re a rather large business. We track how we can continue to provide advanced capabilities to our patients and community still within an acceptable cost structure.

So, all of those sorts of things are measured as you’d expect them to be. I think that is the most important thing that is specific to digital capability to be able to measure and track progress. The nature of how we’ve defined progress outside of these broad buckets that I just mentioned would be different from case to case. But measurement is one of the most important things we can do post-launch. You’re not done when you’re launching a product or a solution. You are never done. The incorporation of the measures and the results that you’re getting should always feed into the next decision cycle and in our case that has a relatively short window of time.

So we continue to iterate on all of the services and products that we deliver to our communities as well as to our team members inside of Novant Health. As we think about how we are acting as stewards of the resource that our companies have that are so important to us ultimately to the health of our communities.

PP: Any final thoughts that you’d like to share with our listeners as it relates to how they could be looking at their digital programs or anything from your own experience as a best practice?

AY: One of the things that has been such an accelerator for us here is the creation of the chief data officer role and corresponding organization, which include the Cognitive Computing Group, which includes Enterprise Information Management Organization. These sort of constructs and the corresponding investment that allowed us to accelerate some of those foundational capabilities t are absolutely required in advance of being able to do any of the more exciting things we’ve talked about that are more functional in nature.

So, getting those foundations right is important. That doesn’t mean you have to take a couple of years to do it. It has been done in other industries. My advice to other healthcare systems is unless you are in need of additional health care expertise, don’t be afraid to pull people in from outside of healthcare because it’s a gift to allow them to participate in such a wonderful industry. And it will be a benefit to the industry to have diverse perspectives involved in solving some of our most complex problems.

We hope you enjoyed this podcast. Subscribe to our podcast series at www.thebigunlock.com and write to us at info@thebigunlock.com.

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

About our guest

Angela Yochem is EVP, Chief Digital and Technology Officer for Novant Health, a super-regional healthcare system with one of the largest medical groups in the US. She and her teams deliver the world-class consumer capabilities, differentiating technologies, and advanced clinical solutions that allow the high-growth system to provide remarkable patient care.

Angela has served as EVP/CIO at Rent-A-Center, Global CIO at BDP International, Global CTO at AstraZeneca, and divisional CIO at Dell. She’s held tech exec roles at Bank of America and SunTrust and held senior technology roles at UPS and IBM. In these roles, she built B2B digital product lines, grew digital retail channels (B2C), created technical services lines of business, and transformed global technology capabilities.

Angela has been a Director for the Federal Home Loan Bank of Pittsburgh, BDP Transport, BDP Global Services Asia and Europe, and Rocana, with experience on Audit, Enterprise Risk, Operational Risk, and Governance/Policy committees. She remains an EIR for Vonzos Partners, a Mentor for SKTA Innopartners, and an Advisor for Dioko Ventures. Angela serves on the board of Freedom School Partners, a non-profit committed to promoting literacy in the Charlotte area, and on the executive team of the Go Red for Women organization, part of the American Heart Association. She is a Trustee of the Charlotte Regional Business Initiative and is an advisory board member for the American Hospital Association Innovation Council and the University of Tennessee Electrical Engineering and Computer Science department.

Angela has a Bachelor of Music from DePauw University and a Master of Science in Computer Science from the University of Tennessee, holds three US Patents and is an author with Addison-Wesley and Prentice-Hall.

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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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Every patient has a right to control where their health data goes

Posted on by arpita

Episode #36

Podcast with Paul Black, CEO, Allscripts

"Every patient has a right to control where their health data goes"

paddy Hosted by Paddy Padmanabhan
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In this episode, Paul Black discusses the next wave of opportunities for Allscripts and how digital transformation is shaping the healthcare sector. Paul also discusses emerging technologies and how Allscripts has embraced cloud adoption for many of its solutions. He believes that emerging technologies such as AI, Blockchain, and voice recognition are improving patient experience, driving better healthcare outcomes, and substantially enhancing the physician’s life.

In the context of the ongoing debate about patient data access and the proposed ruling by the HHS, Paul states that Allscripts strongly supports legislation or regulations that address information blocking in healthcare. He suggests that health systems, looking to harness innovation, must bring together outside help with industry experience and their own organizational knowledge from a clinician standpoint to accelerate transformation.

Allscripts CEO Paul Black in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “Every patient has a right to control where their health data goes”

PP: In terms of technology for the healthcare industry, what do you see as the next wave of opportunities for Allscripts?
PB: Allscripts has done a lot of work over the last 25-30 years to get the entire platform, especially in the United States, to be completely digital. It is a very exciting place for Allscripts to be in especially from patient safety standpoint, from our capability to have efficiencies and just to ensure better patient care and better patient access to that care. Also, the digitization of patient records enhances the ability for health systems to deliver care protocols in rural areas just as they deliver care protocols in a large academic medical center in a large populated urban area. This is transformational, and in a transformed environment you are actually going to practice medicine differently for the rest of your life. So, from here, going forward, we’ll never go back to paper. We’ll never go back to the way we used to do it. The entire platform has been not only digitized but transformed. So, again, we look at that and we see a lot of opportunities for that going forward.

PP: So, Paul, you mentioned transformation. Everybody talks about digital transformation. Do you have a definition for it at Allscripts? What do you see as big themes playing out in the name of digital transformation today?
PB: There are three or four things. We have, in many cases, tried to anticipate where the industry is currently so that we can have platforms that are relevant to people that are doing business in a transformed and digitized area. So specifically, around interoperability and population health, our definition around digital transformation has to do with the ability to take a vast amount of data from multiple different electronic medical record organizations and companies to give a unified and community view, a single view, of that patient’s information. We’ve been doing that for quite a while now. And I think that’s an important construct that you have to have which is foundational.
Infrastructure has to be in place because no one is ever going to get to one record. You are always going to talk to the state, you are always going to talk to insurance companies. People have different electronic medical records or other information systems that have clinical information in them that are relevant to that individual person who has a condition that you’re trying to help them recover from. So that’s one.
The other one that I think is important, is the consumer. We all have talked about the concept of a patient being a consumer. Unfortunately, the status they have as a human being is defined as one who has become sick, met an accident, or some episodic condition that they have been battling for many, many years. But the consumer, is somebody who proactively looks for and shops, compares and writes, and, you know, is really actually very actively is engaged in the buying process. And specifically then for us in healthcare, the consumer is somebody we have to really be aware of and what their patterns are, what their likes and dislikes are, how they like to be treated, how they like to access the health system and what kind of requirements they have when they are on their smartphone or their iPad. What are the services they are looking for that weekend, that night, that evening; where they can quickly go in and get certain mobile care.

PP: What is your take on the debate that’s going on today with regards to providing access, specifically the HHS proposed ruling around providing access and where do you think we are today? Is this something that you see being resolved in the near term or do you see that being an ongoing concern?
PB: The regulations that are out there and being proposed are going to be distributed very quickly, I think. We actually have been very heavily engaged in this process going back to the 21st Century Cures Act. I think it is about going back to a very foundational and important pillar inside the EHR community. We have a very important voice in Washington, D.C., and on multiple different topics I’ve had a chance to testify in two separate congressional hearings on the topic.
We met two months ago with HHS Secretary Alex Azar and Joe Grogan. Joe is the White House Director of Domestic Policy. We had discussions in this specific area and the specific arena, and there are a lot of things that we really like about it. There are just a few things that we asked for some further clarification around intellectual property protections, market-based pricing models for information exchange, and the appropriate scope of certification requirements. They’ve been very good about listening and have been very considerate of the feedback. We’ve had a very constructive dialog with them on those topics.

PP: I heard you say that there have to be some guardrails around how the access is provided in order to protect patient data. Did I hear you right?
PB: Yes, you did. The guardrails are already in place that we are adhering to. Anybody in this industry has been extraordinarily cautious about and respectful of the laws that are out there for all the good reasons. Specifically, on this one, going back to the regulatory environment, we have never advocated against legislation or regulations that address information blocking in healthcare. We strongly support that and have been part of this open infrastructure ecosystem since 2007. It’s interesting that same year the iPhone came out too.
We believe that people should have access to the data and that system should be much more open at an API level, which the legislation also requires more than just the HL7. FHIR also been very important in that area. But we also believe, importantly, that every patient has a right to control where their health data goes when it moves or doesn’t move, and who sees it. And so, we actually grant consent at the patient level with our consumer platforms. We have been advocating for that, and that was one big piece of this legislation that we were extraordinarily supportive of. We’ve always been encouraging of the legislation to give the patient full control of their patient medical record.

PP: Where do you see are the big use cases for AI, machine learning, advanced analytics in your work and in some of your clients?
PB: There’s been a fair amount of work that’s been going on for a long time. Over the last two or three years, AI is getting a lot of attention for things like Watson and some of the other big players that are out there using artificial intelligence for cancer, or radiology. They are using it for the substitution of a human to be able to look at certain data patterns and to come up with a different answer or a better answer and a more efficient answer. So, I think those are a couple of examples of the way the people are looking at it today. I think that there will also be, from an efficiency standpoint, a lot of artificial intelligence utilized for that.
The other piece of data that comes in is when you’ve automated the shop for healthcare. Not only do you get clinical information in real-time, but you also get consumption information in real-time, such as how efficient organizations are about moving patients through the system. Will that be the ED wait time? Or components like that all the way through how many resources were consumed in order to do a certain specific surgery and how much time it took in the overall costing of that? I think it’s going to be a lot of fun to track. What we like a lot are the capabilities once the data is stored, structured and now we have to study it, but also to use the data crawlers and some other capabilities that exist out there to give us new insights about populations that we can go then put specific programs around.
When you think about it, you’re financially responsible for a large community of people. That’s one element at the big data level that I would look at. By big data, I mean you’re looking at multiple hundreds of thousands if not many people at once and you’re looking for specific conditions and specific precursors of that disease warning signals or flares or other weird events, that if you follow closely, you might be able to prevent the further deterioration of that patient. Whether that be COPD or cancer or some other areas that are out there.
So, I think those are all capabilities that exist today that I think are exciting and those are capabilities that many different organizations are getting much, much better at utilization.

PP: Do you think we are seeing more benefits from non-medical use cases of AI than in the actual practice of medicine?
PB: I probably would not agree with that. There are equivalent use cases for the financial information around HCC coding, around appropriate billing, around the financial side of healthcare. Anytime you look at large rooms of human beings that are staring at screens and are punching away on their keypads – I think there’s great opportunity for that. But I wouldn’t necessarily say that overreaches what the clinical benefits are in the clinical usage of those systems are today. But I do think there is a substantially large amount of that.
Things like blockchain are probably, at least currently, best suited inside of financial elements in insurance companies and other things inside of healthcare that makes it a great tool. But there’s also the clinical side of blockchain, another great example of that use case would be Medrec. Medical reconciliation of all the different medications that people are on would be a perfectly well-suited application for a blockchain. And it’s a big, big opportunity.
It is also a big problem if you do not properly understand every single medication that a person is on. And unfortunately, many times, the number of medications that people are on, they don’t really remember everyone that they’re on either. Therefore, as a pharmacist, you are engaging with a bunch of different systems at once – the consumer side, the hospital dispense, the local pharmacy dispense, the mail order, and making sure that all of those medication administration records tightly fit together and they all have a ledger approach with which blockchain can lead a very simplistic way to be able to make that happen, which is pretty exciting.

PP: Can you comment on where we are with voice recognition and specifically may be what you’re doing at Allscripts to incorporate voice into your solutions?
PB: Voice recognition has been out there for the last 25-30 years, especially in radiology departments. It has been great. And, probably on a scale of 1 to 10, 10 being finished, that’s probably somewhere at a 9. So, there is the ability for voice recognition to replace a keyboard, substantially enhance the physician’s life.
There is a lot of experimentation going around taking that technology and extrapolating that and using it into a very busy primary care clinic and having the caregivers being able to talk to a device that’s in that room and not have their hands on a keyboard. We call that the keyboard-less visits. And we have clients that are working on that today at scale and they’re getting a lot of value out of that. They’re clinicians like that, because anything that takes them away from having to hunt and peck on a computer keyboard, they’re all in, especially when you’re trying to see 40 to 60 patients a day. It really can help compress the amount of time that they’re spending, doing documentation. Chart reviews and other things like that in advance are still needed. But that’s another very important use case. I think that will only continue to enhance the experience that clinicians have and the usage of will continue to be accelerated outside of radiology into almost all areas of the practice of medicine.
That’s certainly the work that’s going on between Microsoft, Apple, and Amazon on this topic and will highly accelerate the efficient and clever uses of the technology that has been out there since the 80s and perfected, about 20 years ago for radiologists. Voice recognition needs to be moved into mainstream clinical care.

PP: Do you see keyboard-less technologies, such as identity and access management for patients through facial recognition, picking up as well from an emerging tech standpoint?
PB: Yeah, there’s a lot of different ways for people to log in, which is another problem. But the two-factor authentication is needed from a security standpoint. And that requirement will be out there, especially for medications, the narcotics, and other controlled substances that are out there. And so, the ability to navigate and identify a person through a palm, a fingertip, a retinal eye scan are capabilities that exist today. It will continue to get better and easier for caregivers to get through who you are. That will form a very important part of the process of being logged into a system.

PP: We’re seeing a lot of cloud data sharing agreements. Where do you see us today in terms of cloud adoption in healthcare? And where do you see the big opportunities?
PB: We have a number of our applications that are a native cloud today. We have other applications that are moving to the cloud. There’s no question that this technology is being rapidly embraced by and adopted throughout healthcare. I do think that they are a bit of a late adopter, but that doesn’t mean the acceleration of that adoption can’t be substantial as compared to somebody that might be in the cloud in other industries 10 years ago.
So, number one is that it is not only coming, but it’s here. And as recently as three years ago, we do business in other countries, a national policy minister for health stated you could not have patient data in a cloud infrastructure. Today, it’s encouraged and considered an extraordinarily important move. For people like us that have applications whether it’s an EMR or other solutions that are out there, that opens up a lot of opportunity. So, from our perspective, the benefit of having something in the cloud is somewhat obvious. The ability to ubiquitously access this data from any device, to have a different, and more robust layer of security, especially when you think about the investments that these organizations – Amazon, Google, Microsoft – make every year in the digital infrastructures and the cybersecurity surveillance capabilities, they dwarf the investment that a large integrated delivery system could ever make. I think that will be one of the more compelling reasons why people move to the cloud.
The third reason would be that the total cost of ownership, not having to do upgrades, not having to buy hardware, not having to have your own local backup data centers, all of that goes away with the transition to the cloud. And therefore, the total cost of ownership for an institution as they look at being able to have a different utility that provides those services to them. While it may not be the total parity today, there’s no question in my mind that over the next decade that service will be performed and that the competition between those organizations, like any other technology, will eventually drive that cost down to a point where the cloud will not only be affordable but extraordinarily attractive.

PP: How are you harnessing digital health innovation in your own product portfolio? And what is your recommendation for health systems that are struggling to do it in a way that doesn’t break the bank?
PB: Well, there are three or four things, I guess I would say. Number one is the fact that when we talk about being open and connected, that we build open, connected communities at health. The word “open” is really important, it’s not just a buzzword. In our ability to not only have that as a culture inside the company but how we build our solutions and the access that we grant third parties to relatively deep level APIs, is an important construct that distinguishes us from other people that have been in this industry as well. Part of that open framework for us creates an incentive for startups to utilize our platform and to partner with us to build their business case, their business model, and to take their innovation into a welcoming environment where they can prove out and test cases, but also get access to clients that are already connected to a network and potentially gets to scale much more quickly. So, we encourage that. We fund some of the people that we work with. We see a lot of different companies. We have over 279 different companies that have written applications that sit on top of our solutions. We have clients that have written their own and sit on top of that environment, that ecosystem that we’re trying to create to support entrepreneurs and support innovation. It has been something that I actually inherited when I first got here. In 2013 we gave out that are in the user’s group a million dollars for the top four applications that have been developed and that sat on top of our ecosystem. So that’s something we’ve got. It’s not a lip service, we actually embrace it and we support it. We have people that are dedicated to helping those folks become successful.
Clients, many of them are building a capability inside their organization, especially large ones, where they have a JV fund, where they’re actually looking for and then putting money into third parties, entrepreneurs who are building applications and have already declared startup status. There are a number of large organizations all over the country that have this business line of helping fund venture capital-backed organizations that are building and innovating new platforms inside of healthcare. There’s a lot of that activity and I like that, and I encourage that, and again, to the extent that those applications that are funded by JVs and supported by large integrated delivery networks are also part of the Allscripts ecosystem. We just think that’s a wonderful, wonderful way to bring innovation to healthcare in a much-accelerated manner.

PP: What is your recommendation to health systems that are looking to harness all this innovation? How should they go about accelerating the adoption of innovation? What are some of the best practices that you’ve seen?
PB: I think organizations like University Hospitals in Cleveland, Northwell, Ascension – all have these funds that are set up and they act. They brought in somebody from the outside typically who had background experience in investing in joint ventures that combine them with the organizational knowledge of what kind of solutions actually would work in that kind of experience from a clinician standpoint is a pretty powerful combination. I’ve got people that know what problems I’m trying to deal with today. I got people that know how to look for, search out and procure dollars and to find the companies that are building things. The combination of those two with them, the ability to immediately inject that solution into a relatively large ecosystem, their own caregivers make it a very powerful combination.

PP: Paul, any closing thoughts? Anything exciting planned for HIMSS that is around the corner?
PB: We love HIMSS. We like to have a lot of people there. A great place to meet a lot of clients, suppliers. We actually do a fair amount of recruiting there. We talk to analysts, both people that follow the industry. We talk to a lot of people that write about the industry, folks like yourself. So, it’s a very efficient way to spend three or four days. We will highlight some new capabilities that we have down there, which is always kind of fun. Talk about the innovation that Allscripts brings to the table and also a fair amount of putting exclamation points around some of your clients’ experience and some of our clients’ success.

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

About our guest

Paul Black is the Chief Executive Officer and a Director of Allscripts. As the CEO, Paul guides the company’s vision to fulfill its global commitment to build open, connected communities of health.

Prior to joining Allscripts in 2012, Paul spent more than 13 years with Cerner Corporation in various executive positions, retiring as Cerner’s Chief Operating Officer in 2007. Paul’s career started with IBM Corporation where he spent 12 years in a variety of leadership positions in sales, product marketing and professional services.

Paul has served on multiple publicly traded, private company and nonprofit boards of directors for companies in healthcare information technology, patient monitoring, healthcare services, healthcare delivery, healthcare device, and consumer internet marketing.

In Kansas City, Paul spent 16 years as Chairman and as an Executive Officer of Truman Medical Centers, an academic safety net health system. He currently is on the board(s) of The Advancement Board University of Kansas Health System and the Harry S. Truman Presidential Library. Paul holds a Bachelor of Science degree from Iowa State University and an MBA from the University of Iowa.

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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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We give hospitals the ability to quickly and securely send patient records to outside clinicians

Posted on by arpita

Episode #35

Podcast with Dr. Peter Tippett, Founder and CEO, careMESH

"We give hospitals the ability to quickly and securely send patient records to outside clinicians"

paddy Hosted by Paddy Padmanabhan
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In this episode, Dr. Peter Tippett, one of the first person to develop a commercial antivirus software, discusses how careMESH is providing easy and secure communication and collaboration between clinicians locally to share digital patient records. Peter also discusses the issues related to information security in healthcare.

Healthcare, like in other industries, requires digital communication in everything, be it care coordination, patient safety, reducing readmissions, unnecessary ER visits, or analytics. To address this marketplace requirement, careMESH makes a set of national secure service that helps health systems to easily communicate about patients and share patient records from their own EHR to any outside physicians/ clinicians, reducing the time consumed by traditional communication ways within health systems.

According to Peter, health systems have started investing in and adopting digital transformation to provide ‘virtual health’ through their own EHRs, EMRs to provide care coordination, social determinants, and enabling home health workers for patients. These health systems are the powerhouse, incubating the innovative startups and providing them the focus they require to make the change happen in healthcare.

Welcome to The Big Unlock podcast where we discuss data analytics and emerging technologies in healthcare. Here are some of the most innovative thinkers in healthcare information technology talk about the digital transformation of healthcare and how they are driving change in their organizations.

Paddy Padmanabhan: Hello again everyone. Welcome back to my podcast. This is Paddy and it is my great privilege and honor to introduce my special guest today, Dr. Peter Tippett, Founder and CEO of careMESH. Peter, thank you for joining us and welcome to the show.

Peter Tippett: Thank you so much. It’s a great privilege.

Paddy Padmanabhan: Thank you. So, Peter, you have a very interesting background. And among other things, you are also the first person to have developed a commercial antivirus software. So, tell us how all that came about.

Peter Tippett: Well, I was one of those tech engineering nuts even when I was a teenager. I was a ham radio operator and a commercial radio engineer and a pilot. I was one of those couple of kids that were allowed in high school to touch the 55-board teletype locked in the closet. And in college, I stumbled into more things. I used a very similar computer in a lab doing really early cholesterol and Hyperlipidemia work. And I used it to automate their analysis and results. And then for my college seasons, I wound up as an apprentice and an assistant for two different Nobel Prize winners. The first guy sequenced the first protein and the second guy, Bruce Merrifield, synthesized the first protein. And I was there, you know, and used computers in his lab to automate that whole process. And along the way was the first guy to synthesize an active immunoglobulin. And of course, all of that got me a scholarship for an M.D. Phd at Case Western Reserve. And then when I was at Case, I was President of the Cleveland Computer Club. I started a software company in my attic trying to do other sorts of things. And when the virus problem came along, I created the first commercial antivirus. It was called Vaccine, but eventually changed its name. We wound up in a booth a few booths down from Steve Jobs at the West Coast Computer Fair. We grew that company, which was called Certus, for a couple of years before McAfee and the other guys came along and we sold it to Symantec and renamed it Norton Antivirus and then grew it in two more years past 300 million bucks. It was the big heydays that everybody likes to hear about.

Paddy Padmanabhan: Yeah. Well, Norton Antivirus. Now, that’s a household name almost.

Peter Tippett: Well, that’s a lot to do with those guys now of course.

Paddy Padmanabhan: Well fascinating story. I do want to spend a few minutes, given your background with software security and antivirus software and so on. I do want to spend a few minutes on this podcast talking about the current state of cybersecurity. You know, healthcare has been the target of cybercriminals for several years now. And my understanding is that it is the favorite industry for cyber-attacks. I read somewhere that the annual cost of healthcare data breaches in the region of four billion dollars and there’s no sign that is abating anytime soon. And four out of five data breaches are attributed to healthcare data breaches, and providers, in particular, are being singled out for these attacks. So, can you kind of break it down for us and tell us what the big issues are today as it relates to information security in healthcare?

Peter Tippett: Yeah, absolutely. Obviously, security is a huge subject. Maybe I can talk you into doing a whole podcast on it down the line. But, you know, security is hard, but it’s really not as hard as we all give it credit for. I’m kind of a scientist in this world and I spent a lot of energy over the last 20-30 years trying to get a sense of how the risk economics really work. And my biggest take home over the years is that we’ve really typically get talked into putting what my mom says is putting the emphasis on the wrong syllable. We have spent a huge amount of money and user equity on things that have very low marginal value and we ignore and allow the simple, inexpensive things that are relatively easy. For example, you mentioned ransomware. The basic solution to that is backup. Nothing fancy. Right. And oddly, using some of these newer information sharing services like my company’s new careMESH offering that gets some of your data accessible in other ways, all by itself is a mitigation for things like ransomware. If you look at the breach science and look at how that works out in risk dollars, there’s really just two things that reduce the overall costs and risk and likelihood of a breach by vast of the majority than all other things combined. The first one is a strong identity, despite what everybody says, making passwords stronger or more complex doesn’t do a squat. But adding a second factor like the code that comes to your phone or a token or whatever, that reduces risk by many, many orders of magnitude. So, turn those things on. That’s really simple. And it is really, hugely strong. The other thing is around network management. Running your own data server and data centers and firewalls and all that stuff is hard and expensive and we’re all error prone. But any one of the cloud providers has a hundredfold more security and ops people than any IT health organizations does. And you know, they have the experience, use the cloud and embrace it. Those are the key issues.

Paddy Padmanabhan: Yes. You know, just coincidentally this morning, I was on a Twitter chat with a group of cybersecurity professionals and a couple of things came out of that discussion. And these are very commonsensical type of things. The two big issues that the participants in the chat pointed out were, one, it’s a cultural issue, less of a technology issue, more of a culture issue. And really educating everyone in the organization at every level to be watchful of phishing attacks or to your point, turn on two-factor authentication. It’s a cultural thing. And so, you’ve got to have the right kind of culture to protect yourself against cyber-attacks. The second thing they talked about was in the context of healthcare the business associates are a big point of vulnerability. So, care to comment on those two observations?

Peter Tippett: Yeah. I mean, you know, the power is clearly in the hands of the attacker if you’ve got a million people and you can succeed at one percent opening a phishing email. That one percent is in trouble. So, a big attack surface is how we talk about that. But two-factor authentication works even against phishing attacks. The bad guy gets your password. So, what? Still doesn’t work. So really, really, you have to do both. Don’t spend all your energy worrying about one thing. You need seatbelts and airbags and then speed signs and all the others, and they all work together to really reduce things.

Paddy Padmanabhan: Yeah, OK. I kind of agree with you. We should do a separate podcast down the road just talking about cybersecurity issues. But for today, let’s switch gears here and talk about your company. Tell us about careMESH briefly, the company and the solution you’ve developed and what does a marketplace need you’re trying to address?

Peter Tippett: Yeah. Thanks so much. I’m a doctor. I spent most of my time doing emergency medicine and paying for all these startups by working at night in the ER, but I’ve long been frustrated that doctors can’t simply send a patient record to some other doctor or to some other clinic. It’s like we’re in the years before the internet ever came along. A huge hospital system client of ours reinforced that for me again lately. They worked at this giant referral academic center. They take care of 20-30 percent of their patients come from more than 25 miles away. You know, when they send those patients back home, half of those doctors get a two-page fax. And the other half get two pages sent to them in the US mail. I’m not kidding. The likelihood of getting a digital record outside of that 25 or 30-mile range is nearly zero. And this is not right This isn’t how the world should work. It drives the doctors nuts on both ends. It drives the patients crazy. Even the average hospital is not at that pinnacle of referrals to the world where two-thirds of their community doctors are using a different EHR than the hospital. Less than 20 percent of those outside doctors routinely get digital-only useful patient data. And almost none of them can communicate back and forth with a big hospital or the doctors or whatever. So careMESH came along to change all of that. We decided to make a set of global national, you know, secure services that don’t require complex IT infrastructure. So, hospitals can easily discharge patients or send referrals right from their own EHR to any physician or practice in the country and not make that other end, have to do anything or buy anything or even know who the heck careMESH is. Like when you send a FedEx, they came along with the idea, which was, give it to us and we’ll get it wherever it needs to go, even if it’s on some weird island somewhere that’s our problem. So, hospitals should be able to simply look up a patient in their own EHR enhanced by our national careMESH provider directory and push the send button or the complete button. So, hospitals can also automate the setting of detailed admission and discharge summaries, not just ADTs and PIDs without requiring the recipient to submit patient panels or log into portals or pull lists of patients or other things like that. So, careMESH is a solution like none other available in the healthcare industry, giving hospitals the ability to quickly and securely send patient records to any outside clinician. Of course, we want to completely embrace the new cloud, compute models and strong identity and modern high-end security and privacy and all that and make those problems go away as well as further participating hospitals. And any big platform can do a lot more than just sending records from hospitals or getting two-way communication going or keeping things digital. Because hospitals need to be able to efficiently share data outside their walls. Care coordination, patient safety, reducing readmissions, unnecessary ER visits, analytics, you know almost everything requires digital communication. So, we want to be complementary to the stuff that already works like HIEs and EMRs. But they just don’t work well enough.

Paddy Padmanabhan: So, it seems like there’s two aspects to what you’re trying to do. One is having a robust provider data management system, process platform where you can go to it as a single source of truth. And it really is the truth as it relates to providing data and then using the same platform or related functionality as a draw on the platform, you’re using it for care coordination, doctor-patient communication and so on and so forth. Am I right? Are these two broad components of your platform?

Peter Tippett: Yeah. We think of it as finding the doctor in the first place or the clinic. I want to send a message to Dr. Smith in Salt Lake City; the patient just knows Dr. Smith right. And figuring out which Dr. Smith and making that part easy from within your own EHR for whoever the clerical or clinical person is. That’s the directory problem. And then once you find the person making it so that just doing whatever you normally do. You know, a doctor’s order to discharge and a clerical person following up with the pieces need to happen to get the record out there or the doctor going into the messenger or the basket or whatever it is in their EHR and finding somebody that’s outside their building and saying, you know, asking them a quick question or something. That’s the directory problem. Then once you find the person, you want all the natural things to happen so that when you hit the complete button or the send button, they actually receive the message and it works. And it’s digital and it helps them at the other end as well. So that’s the delivery problem. Of course, it’s not as easy as all that you’ve got to HIPAA get going and compliance and interoperability and make it easy on the other end and make the reimbursements all happen. Big compliance and incentive payments from PI and all that stuff work. But yeah those are the main two components.

Paddy Padmanabhan: Yeah. Let’s talk about the competitive landscape that you operate in. Provider data management has long been an issue in healthcare. If I recall it right, it’s like a three billion-dollar problem or something like that. There are lots of companies trying to address it and using different technology. You know, there’s one aligned group of companies using blockchain, for instance, to create a single version of truth among other things. And everyone every doctor that I’ve talked to would love to have this single source of truth where they don’t have to keep on credentialing them again and again. They go to this one place where, you know, everybody has it all in one place, and it’s all a single source of truth. But it is a competitive landscape and lots of people are trying to solve this problem as well. At the same time, it comes to the other aspects of your platform, the care coordination, the messaging for the EHR vendors, Epic, Cerner, big tech firms. How do you see yourselves in this competitive landscape and what do you think makes you a little bit different?

Peter Tippett: Yeah. The technology like blockchain versus not seems to me to be pretty relevant. The most important thing is, as you said, figuring out how to solve, I call this “the surround problems.” I wrote one of the chapters in Ed Marx’s book on innovation – ‘Voices of innovation.’ And I know you’re working a little bit with him. What a great project you guys are working on. And it seems to me that things that actually get the job done when there’s a huge legacy installed base of things is not trying to fight the installed base, but trying to complement it to work within the system that’s already there and figure out how to extend it relatively easily. The trend of making programs to decide you’re going to blow up whatever is there and start over again is kind of crazy. So, if you can make a directory, you know, ours is FHIR enabled and it’ll work through a browser or a phone or any of that. But that doesn’t help the hospital. You need to make it so that it just becomes the natural directory that’s used by all the services that already use the directory in the hospital like your Epic in basket or the discharge floors or whatever. It doesn’t make that disappear so that no workflow changes happen. And then you’ve got the other issue. But when you get to the competitive things, I think of this as healthcare is wildly local and always has been. And the technology that follows it has been local as well. So, it’s been really easy to hire a big contractor and spend a million bucks hooking your hospital at the other hospital. After you spend a year planning and you’re doing in a year fixing, it works. But now you’ve got two points connected. Well, you know, if you do the math, there’s five thousand plus hospitals and two or three hundred thousand clinics. That would be two hundred three hundred thousand factorial connections and BAAs and all that. That’s by the way, more than our grains of sand on earth. So, this is stupid. This isn’t something that could possibly scale. So, what we need is analogous to what we got when we built the internet. We need a way that everybody can use the same network for all of the basics to not to find the other guy, but also to get something to them without file size limits or anything like that. We need something that works with the EMR vendors and the HIEs and extends their functionality naturally. And we need something that enables all the care coordination platform. I don’t want to build a care coordination platform. I just want to make the ones that are out there actually work for somebody who isn’t involved or some other end that didn’t buy the other end. Making everybody buy both ends of a fax machine or a telephone is nuts. That’s not how those industries evolved and ours can’t get there either.

Paddy Padmanabhan: So how do you build a business case? I understood what you said that you’re working with the existing technology stack solutions that are out there and making them better. So how do you actually build a business case? What do people look for when trying to justify investment in your platform?

Peter Tippett: Yeah. I was on the PITAC, the President’s Information Technology Advisory Committee. I know it’s going on 20 years ago with Baylor and that whole gang. And we said if health, you know, this is a triple aim, in my words, slightly. If health care could only use information technology in rough parity with, the banking or other industries would get three things right. We’d get wildly healthier people and better long lives and all that. We’d get wildly lower costs to our study in the PITAC showed about 70 or 80 billion dollars a year. But the Institute of Medicine came along and did the big study and came to 700 billion dollars a year of savings for the country. And we get an entirely new kind of science. But other than that, it’s, you know, it’s probably not worth doing. So, we’re all married to this, right. And we now have computers everywhere. But there is pain. Everybody hates them. That’s largely because we haven’t had this sharing in the internet part that makes that work. So meaningful use came along we checked our 25, 15 or 20 or 10 or 16 boxes and got our checks. And now it’s switched to PI, promoting interoperability. And the PI penalties are real. Two of the six criteria are called referral loops or HIE measures or, you know, getting your care coordination going. They explicitly require getting of facts for a large proportion of referrals and discharge and transitions of care out of your own organization, 40 of the 50 points you need for PI and that’s 2 percent or 3 percent of your hospital payments from Medicare. So that, you know, for a medium or a bigger hospital, that’s 5, 10, 15 million bucks a penalty. So, there’s real meat now behind some of those and those the screws are tightening a little bit on that arena. And so, there’s some value there. We see the biggest value for getting this working, you know, the two thirds or three quarters or whatever it is of doctors and clinics that don’t work for you in a hospital. We really need to coordinate with these guys. In the past, we’ve ignored the people on the other side. But now that we’ve fixed the inside and it’s possible to do all the basics in the hospital, now it’s time to sort of extend. I hear this all the time from the CIOs. We’ve spent the last five years making this work at all. Now if we can only get the outside provider’s data and get them engaged and make it so that their job is easier and maybe make it so that they get some PI benefit or efficiency benefit, we’re still spending a huge amount of our time on the telephone and waiting around for the other doctor to talk to the other doctor or hiring a massive care coordinators to call and to show up at eight o’clock every morning and dial for dollars. And this is all nuts. This is 20 years ago. The internet fixed that for other industries. And it’s easy enough to find the efficiency value of tightening up your referral network and getting above 50, 60 percent referral leakage. And, you know 2, 3, 5 percent improvements in referral leakage add up to many millions of dollars of new revenues for a hospital.

Paddy Padmanabhan: Yeah, it’s very interesting. You mentioned banking and you mentioned how other industries are much further ahead. And John Glaser, who is the former CIO of Partners Healthcare, who is on my board of advisors, he wrote an article about this in the Harvard Business Review, where he pointed to this exact same contrast between banking and healthcare. And he makes the argument that you don’t have to do the whole hog, do everything the banking has done. But even if you do it selectively and move the needle, their significant gains to be had. And one of my other guests on the podcast, Daniel Barchi, who is the CIO of NewYork-Presbyterian, he made a very telling comment, he said we have really low thresholds today for digital engagement in healthcare. If somebody uses an online platform just to schedule an appointment that counts as digital engagement and that counts towards digital-enablement patients, and it can qualify you PO points for all kinds of incentives or conversely, penalties as the case may be. Healthcare I think is very unique in that regard because it is a system of incentives and penalties that are driving in many ways digital adoption. Is that a fair statement?

Peter Tippett: Yeah, I think so. You know, I think that the regulators have the right end game in mind. And I think that the knobs are roughly aligned and reasonably aligned. But nobody no business aligns themselves around regulatory incentives unless it’s also valuable to the business. I’ve had I can’t tell you how many CIO discussions I’ve had where they said, why aren’t you worried about this three-million-dollar penalty? And the answer is, if I spend so much of my energy worrying about that I wouldn’t do my business. We have to solve our real problems inside the business. And if we can make it align with getting two or three or million dollars or 10 or whatever it is, the feds fine, right? But it can’t be the principal driver. And so, the argument in banking is they’ve got a simpler data set than we do in healthcare, and that’s true. But tearing things down to the simple issue, you know, meds, problems, allergies, and demographics get that actually working, make it actually digital and get it sharing in both directions and make it work easily, whether at the other end is using a browser or there’s hundreds of EMR as it might be when your brother in law invented and there are twelve other users in the country that you still have to make it work with whatever the other guy is using and getting down to the basics and making the communication work at a really basic level is the key. And you know, once the basics are working, it’s easy enough to extend those a little bit.

Paddy Padmanabhan: Yeah. So, we are at the close here Peter. I would just love to hear your thoughts on what you’re seeing, your customers and health systems, in general, investing in as it relates to digital transformation. What are the top two or three things that you think that you see them focused on?

Peter Tippett: Yeah, I think that as a community, the health systems and IT activities in hospitals and bigger health systems has gotten the inside job pretty well under control. They are feeling like they’ve got, you know, actual functional EMRs, EHRs that actually do the basics and people are being productive with them on the inside. And so, I think there is a view towards the outside. We call it different names of call care coordination, we call social determinants, we call it enabling, you know, the home health workers, all those. We get lots of different names for all this stuff. In the end, it’s very virtual health. It’s getting, you know, getting the communication working. In the case of B2B, getting it working among providers means that you don’t have to force the patient to carry the record or come get it or be the middleman. And everybody wants the patient to have the data and be able to deal with it. But none of us make it. It doesn’t make a lot of sense to force the patient to be the connectivity link. So, I think that we’re getting towards this place in our world where we are enabling the communications. These platforms like carequality and the national sharing platform they’re getting some traction. The vendor platforms by Epic and others, they’re getting good traction. They enable good pieces of what needs to happen. But they don’t enable two-way communication. They don’t enable messaging. They don’t often enable giant things like x rays, sharing or other pieces. They often don’t enable a little guy very well on the Oddball platform. And so, you know, providing the glue that sort of fills in the gaps between the stuff that does work seems to me to be the place to be. And I think the venture community and the venture incubators and hospitals and health systems and those kinds of groups, they’re really a powerhouse. They’re the ones that can get the little startup guys and the new innovation guys. They can keep them on track. They can give them the focus they need because all kinds of people have good ideas. But all of us inside, you know, we largely are scientists in this world and businesspeople and the venture world in an incubator, they’re supposed to be experienced. And the good ones do help focus on actually making the change happen.

Paddy Padmanabhan: That’s said. In fact, in my recent podcast, I had a couple of senior executives from Epic and kind pretty much said the same thing that you just said, at least in terms of their product, focus on their platform, focus in terms of facilitating the seamless exchange of information, if you will. Well, Peter it has been such a pleasure speaking. There’s a lot that we can talk about and hope to carry on with the conversation and have you back on our podcast sometime soon. In the meantime, I wish your company, careMESH, and your team all the very best and look forward to staying in touch.

Peter Tippett: Great. Thanks so much.

We hope you enjoyed this podcast subscribe to our podcast series at www.thebigunlock.com and write to us at info@thebigunlock.com

About our guest

Dr. Peter Tippett is Founder and CEO of careMESH, former Chief Medical Officer of Verizon, and a leader in Health IT transformation, information security and regulatory compliance. Among other start-ups, Tippett created the first commercial anti-virus product, which became Norton, and founded TruSecure and CyberTrust. He was a member of the President’s Information Technology Advisory Committee (PITAC) under G.W. Bush and served with both the Clinton Health Matters and NIH Precision Medicine initiatives.

Tippett is a physician, board-certified in internal medicine, and was Research Assistant to R.B. Merrifield (Nobel Prize, 1984) and Stanford Moore (Nobel Prize, 1972) at Rockefeller University. He received a PhD in Biochemistry and an M.D., from Case Western Reserve University, and a B.S in Biology from Kalamazoo College.

Throughout his career, Tippett has been recognized with numerous awards and recognitions — including E&Y Entrepreneur of the Year, the U.S. Chamber of Commerce “Leadership in Health Care Award,” and was named one of the 25 most influential CTOs by InfoWorld.

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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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We essentially see ourselves as stewards helping clients manage their data

Posted on by arpita

Episode #34

Podcast with Seth Hain, VP of R&D and Sean Bina, VP of Access and Patient Engagement, Epic

“We essentially see ourselves as stewards helping clients manage their data”

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In this episode, Seth Hain, Vice President of R&D and Sean Bina, Vice President of Access and Patient Engagement at Epic discuss the next wave of opportunities for Epic and how the company has evolved by focusing on patient experience and advanced analytics.

At Epic, the focus has always been on providing patients with access and tools to view and have control over their data. Epic works with over 300 health systems today to help them manage their data. Over 160 million consumers have or are using its MyChart patient portal which has been around for nearly two decades. The company uses advanced analytics such as AI/ machine learning and monitors how they are performing on different populations before embedding it into workflows, be it clinical-facing or patient-facing.

Epic has lately started focusing on providing transparency around healthcare costs and has been working on creating accurate estimates for patients so that they have price transparency at the point of care.

Welcome to The Big Unlock podcast where we discuss data analytics and emerging technologies in healthcare. Here are some of the most innovative thinkers in healthcare information technology talk about the digital transformation of healthcare and how they are driving change in their organizations.

Paddy Padmanabhan: Hello again, everyone and welcome back to my podcast. This is Paddy and it is my great privilege and honor today to introduce my special guests. We have two of them today, Sean Bina, who is a Vice President for Patient Experience with Epic and Seth Hain, who is VP of R&D for Epic. Seth and Sean, thank you so much for joining us and welcome to the show.

Sean Bina: Thanks for having us.

Seth Hain: Thank you.

Paddy Padmanabhan: You are most welcome. So why don’t we get started? Maybe you can give us a little bit about your background and your current roles at Epic for the benefit of our audience.

Sean Bina: Yeah, so I’ll start. So, this is Sean and I started at Epic 23 years ago doing implementations of our systems. And then over the years, I’ve worked with a variety of our different products and now focus my time on the patient experience. And that’s really my goal, to help patients get connected into their health and wellness in a way that they’ve never been able to before.

Seth Hain: My name is Seth and I started a little after Sean. I’ve been here for about 15 years and when I came to Epic, my focus was on architecture and the kind of systems infrastructure behind the scenes. And then I combined that with my prior experiences around mathematics and focused on and continued to today the research and development around analytics and machine learning and in particular embedding that type of intelligence into workflows, be it clinical facing or patient-facing, for example. And the tools that are used throughout the system for analytics and machine learning.

Paddy Padmanabhan: And between the two of you, I would argue that you are looking after the top two focus areas for health systems today – patient experience and advanced analytics. So, I’m looking forward to this conversation. I want to start with this, now we have near-total penetration of electronic health record systems in the country today. Of course, it’s been a great run for Epic as leaders in the market. So, what are you seeing as the next wave of growth opportunities for Epic?

Sean Bina: So, we see a few different areas where we’re continuing to do a lot of work. One is we just continue to work with our customers to expand the adoption of Epic and then to add new additional modules. One of the things that we’ve learned over time is that every specialist needs a system that’s really designed specifically for them, whether they are core things that all physicians and clinicians use around ordering and reviewing results and doing some basic documentation. But then there’s a lot of subspecialty support that’s needed for doing things like managing images, for registry support and for doing the kind of specific documentation within a given subject area. So, we continue to go deeper and deeper into those areas to create a great experience for physicians. The one thing I would add is when we look at the industry in general, we do see our customers are really focused on three core areas. One being patient experience, two being analytics, but then three is really bringing the joy back to practice for physicians.

Seth Hain: I would also add that the space around healthcare continues to change and evolve. And I think there’s a lot of opportunities as we start to look at and see more collaboration between, say, payers and providers in the space. There is an opportunity there to help facilitate faster exchange that benefit both the provider and their workflow, but also the patient and the care they’re receiving in a timely manner. And that expands as you start to think about a broader definition of health. Thinking about things like dental, long term care, even where people get care, be it a telehealth encounter through, you know, they pay from the app directly on their phone, or they’re in a retail clinic and they just need to swing by for a flu shot and making sure that’s a continuous experience from a health perspective.

Sean Bina: The other thing that we continue to work on is we continue to move internationally. So, you know, outside the U.S., we work with an increasing number of countries on our software and there’s kind of a wonderful cross-pollination that we get as a result of that. So, for example, we’ve been working a lot with Finland and they’re very focused on social determinants of care, really, really focused on reducing the need to get into the hospital or readmissions into the hospital. And so, a lot of the work that we’re doing with them around their social care system then ends up benefiting our U.S. customers.

Paddy Padmanabhan: Right. Right. And we’ll unpack some of these, especially around the emerging tech stuff in the context of digital transformation, which is what we mostly focus on as a part of this podcast. So, let me ask you a simple question. What is your understanding of the term digital used by everyone? And almost everyone has a definition for it. And how do you define digital? What is your understanding of the term and how is it impacting all your choices or investments in health systems, specifically from your point of view with your clients?

Sean Bina: Yeah. If you don’t mind, we take a quick trip back down memory lane. You know, when I started back around 20 plus years ago, the world was very different in terms of what was available from a digital perspective. You know, there weren’t integrated ambulatory inpatients solutions. You couldn’t do an end to end revenue cycle system that covered all your hospital and clinics. And so, people were using best of breed systems and trying to cobble systems together to manage all of that. And until around 2003, there wasn’t even such a thing as a patient portal. So, one of the things that when I think about what it means to be digital today, it’s obviously changed over the years. But I think it’s important to remember how far we’ve come that we now do have fully integrated systems that cover all the kind of food, warmth, and shelter that is needed by healthcare organizations. So that now we’re getting to the point where we can do a little bit more of the poetry.

Seth Hain: I think that depending on who you ask or the definition of digital transformation, you tend to hear a pretty different perspective. Some people immediately come at it from the patient experience perspective and the possibility of having access to health care through your phone at any point in time. Others and I tend to take a foundational view of systems perspective on some of these topics. You know, start to also bring in things like cloud computing behind the scenes and the running of machine learning algorithms on data that is flowin