Completing the Puzzle: Where does Virtual Care Fit in Patient Expereience

July 11, 2023

Panelists: Lee H. Schwamm, MD (moderator); Sara Vaezy, MHA, MPH; Alexandra Morehouse, MBA

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00:08Wonderful. Well,
00:08I'd like to welcome you all today.
00:10My name is Doctor Lee Schwam.
00:12I'm the Vice President of Digital
00:14Patient Experience here at the Mass
00:15General Brigham Health System in Boston,
00:17and I'm going to be today's moderator.
00:20This is our session on clinical
00:22appropriateness in virtual care.
00:24And again, thank you for your
00:25participation and interest in the session
00:27and thank you personally very much.
00:29To all the panelists who are an
00:31extraordinary group of leaders in
00:33the field who've joined us today,
00:35all the sessions will be recorded
00:37today and they'll be available
00:38after the symposium at
00:43www.virtualcareconsensus.com.
00:44Remember to use the Q&amp;A
00:46function during the panels.
00:48Panelists will do their best to try
00:49to answer the questions, but if not,
00:51we'll post additional answers on
00:53the website after the session
00:55and if you have any difficulty
00:57technically during the session.
00:58You can either e-mail digital
01:01media at partners.org or call
01:04857-282-6470 and we can try to
01:06resolve the problem for you.
01:07So as you know, this is now an annual
01:10tradition and we bring together
01:12subject matter experts from across
01:14the country and across organizations.
01:16We did our first session in 2020,
01:19which really focused on rethinking
01:21curriculum competency and culture
01:23in virtual care in the context
01:25of the COVID-19 pandemic.
01:26We really focused on defining A
01:29framework for assessing competency
01:30for training our residents and a
01:32junior faculty in virtual care and
01:35also addressing the challenges along
01:37with the workflows and the strategies
01:40and the best practices around that.
01:42That work was published last year.
01:45And in 2021,
01:46our second symposium really shifted
01:48to focus on quality frameworks,
01:50how they've evolved over organizations
01:51and how we need to think about
01:54and align in person and virtual
01:56care quality frameworks.
01:58So that brings us to today and you know,
02:01virtual care is basically become
02:03a mainstay of healthcare now,
02:04from treating chronic conditions
02:06to more acute changes in health.
02:09Providers all across the country are
02:11using virtual care really across
02:12a wide variety of of indications.
02:14And I would say that we would
02:16all agree on this panel that in
02:18this modern digital world,
02:19health systems have to continuously
02:22evaluate what modality is right for what
02:25setting and how do we turn this into
02:27a conversation about appropriateness,
02:29appropriateness as it relates
02:31to clinical indications,
02:32payment models and breaking
02:34down the barriers that exist for
02:37patients both personal.
02:38Digital and the social
02:41determinants of health as well.
02:44So we'll also cover some of the
02:47complexities and the barriers
02:48around reimbursement and and how
02:51how challenging that can be for for
02:54patients sometimes for providers and
02:56health systems and and the patchwork
02:58that exists across the country.
03:00We're going to have five panels today and
03:03we'll walk through the sort of spectrum of.
03:08How virtual care fits within the big
03:11broad digital patient experience?
03:13How we can think about better job
03:15achieving digital HealthEquity?
03:17How to dismantle the silos between
03:19virtual care and mental health
03:21that currently exist,
03:22thinking about clinical appropriateness in
03:25individual patient care delivery models?
03:27And then lastly,
03:28what does it take to really achieve
03:30payment and coverage parity for
03:32virtual versus in person care?
03:34So let's go to the next slide.
03:39And again here, just a reminder,
03:41you can see where you can find the
03:42slides and how you can reach someone if
03:45you're having any difficulty. Next slide,
03:49I've talked to you before about the
03:51overview of the symposium and here's
03:52the reference to academic medicine,
03:54where our first symposium was
03:55published and our second one is
03:57under review at another journal.
03:58Next slide. And I just gave you
04:03the overview of today's symposium.
04:05And now let's pivot going to the next
04:07slide to talk about the first panel,
04:10panel one, which is going to be
04:12called completing the puzzle,
04:13where does virtual care fit
04:15in with patient experience?
04:16And take me to the next slide please.
04:19And one more.
04:20So here we are.
04:22And the next slide I believe
04:23we'll have our yes.
04:24So I am really delighted to be moderating
04:27this conversation with two of my.
04:29Colleagues,
04:29one I met recently and 1:00 I've
04:31known for quite some time,
04:32Sara Vaisi,
04:33someone I've known for quite
04:35some time who is the Executive
04:36Vice President and Chief
04:37Strategy and Digital Officer for
04:39Providence Saint Joe's Healthcare.
04:42This health system is a really
04:45remarkable health system,
04:46I think more than 50 hospitals,
04:471000 clinics, 5,000,000 patients.
04:49Sara has really deep experience
04:52in developing and leading system
04:54strategy and thinking about.
04:56How to fit together all of this cross
05:00collaboration between a different orgs
05:02within a large corporate structure
05:04and drive digital innovation forward.
05:07I'm joined as well by Alex Morehouse,
05:10who is Chief Marketing Officer and
05:12Chief Digital Officer for Banner
05:14House where she's been since
05:162015 and has basically overseen,
05:18believe it or not,
05:20a half a billion dollar transformation
05:23of digital initiatives.
05:25That have increased customer
05:28experience transactions taking
05:30digital transaction volume up from
05:323,000,000 to over I think 200,000,000
05:34a year and has implemented an A,
05:38I and machine learning platform
05:39for for customer experience.
05:41She's had numerous years of experience
05:43in and outside of healthcare and
05:46and major American corporations.
05:49So I I really,
05:50I couldn't speak more highly of this group.
05:53And so let's flip to the next slide.
05:56And these are the objectives
05:57that we're going to talk about,
05:59the three of us as we go through
06:02this moderated session.
06:03But before we do that and dive
06:05into these questions,
06:06which I'll bring up again at the end,
06:07I'm just going to run through a
06:09quick set of slides to sort of
06:10level set us for the conversation.
06:11So next slide,
06:13So what is virtual care as opposed
06:16to telehealth, telemedicine,
06:17a lot of these terms are synonymous,
06:19but virtual care has come to.
06:22Embody really the broad array of
06:25of virtual direct to patient and
06:28provider to provider care that
06:31is blossoming under the COVID
06:33experience Next slide.
06:35And so this is a an article that
06:37I was editorial I wrote in Health
06:39Affairs almost a decade ago that
06:41was really talking about back then
06:44this upcoming disruptive innovation
06:45and transformation of healthcare
06:48that that telehealth which was
06:49the term we used at the time.
06:51You know,
06:51ought to adhere to if we were going
06:53to get real value out of this.
06:55And I would just highlight a few things,
06:56untethering traditional revenue
06:58expectations for this work.
07:01After COVID,
07:02we're going to have to be thinking
07:03about that again quite carefully,
07:04really understanding expectations,
07:06deconstructing the healthcare
07:07encounter and building it up again
07:10with the component parts and
07:11really being open to discovery,
07:13something that I think my 2 panelists
07:15have have really done an amazing job at,
07:18and redesigning care to improve value.
07:21Which is really important.
07:23Next slide,
07:24so this is a slide from Craig Clay
07:27Christiansen's work talking about
07:29the nature of disruptive innovation.
07:31And I think what we need to remember
07:33is that we've built systems that have
07:36performance sometimes in some cases
07:38that are more than customers can
07:40really use or access quite frankly.
07:42And disruption generally comes
07:44from innovators who start off
07:46offering services that are.
07:48Non competitive,
07:49they're not services that the that the
07:51established company in blue wants to offer.
07:53They're they're low margin,
07:55they're low yield,
07:56they're viewed as inconsequential.
07:58You might think of virtual
07:59urgent care in that bucket.
08:01But those organizations grow
08:03in competency and skill.
08:04They learned quickly and before
08:06long they dethrone the the,
08:09the existing champion and I think
08:10we're at that moment in healthcare.
08:12We really have to think carefully
08:14about what we're providing and
08:15what our risk is of disruption.
08:17Next slide.
08:17You might say that face to face
08:20evaluation and what I call pixel to
08:22pixel evaluation reflect that that
08:24transition zone and and so we really
08:26need to think about how to embrace
08:28this or risk being dethroned by it.
08:29Next slide,
08:32this is just a example from a
08:34paper we published from our own
08:35experience showing you that looking
08:37at the traditional adoption curve.
08:3995% of our providers adopted virtual
08:41care within six weeks of the start
08:43of the pandemic and once they adopted
08:45they largely continued it indefinitely.
08:47And so this is not your typical
08:50innovation adoption curve,
08:51this is an exponential adoption curve
08:53and I think we've we're likely to
08:55see more of that in the near future.
08:59Next slide,
09:00so I love this slide OO which is old
09:05organization plus new technology
09:07equals expensive old organization.
09:09So we better be really careful.
09:10We don't throw a lot of technology onto
09:12an old governance model and expect miracles.
09:15Next slide,
09:15I'll just let you know that percolate
09:17in your minds.
09:18So our own experience here at Mass
09:20General Brigham has been to start
09:22looking at all of our different
09:24platforms and start collapsing them into
09:26a single digital front door for care,
09:28so that our patients have a more seamless
09:30experience whether they're in patients.
09:32Ambulatory in a doctor's office in
09:34their home wearing a remote monitor.
09:36We've got to make it simpler for people.
09:38Next slide.
09:42And this is just a metaphor I've used before.
09:44The digital mall, right?
09:45This is really inspired by work
09:47from people like Sara and others
09:49who've really been thinking about
09:51consumer engagement platforms.
09:52But if we lock ourselves into identity
09:55only through the epic My Chart feature.
09:58Where people have to be fully identified
10:00and bonded before they can have
10:01any digital interactions with us,
10:02we're going to be dramatically
10:04limiting the kinds of services
10:05we can provide and the kind of
10:07personalization that people are,
10:08are looking for.
10:09So we've got to build a mall around our EHR.
10:12We've got to really build a mall
10:15that's designed explicitly for an
10:16exquisite patient experience and it
10:18has to be accessible to everyone
10:20with all types of limitations,
10:22be they physical,
10:24cognitive or other forms of disability.
10:27Or whether they be limitations in
10:29digital literacy or or you know,
10:32English proficiency next time.
10:35So the more we know about you,
10:37the bigger that door is going to be.
10:38So if we don't know anything about you
10:40and you're just an anonymous browser,
10:41you're not going to see very much.
10:43The more we know about you,
10:44the more we can offer you.
10:45And when you're fully identified,
10:47that digital front door is wide open.
10:49So part of what I'm going to be asking Alex
10:51and sorry to think about is how do we,
10:52how do we figure out how to make that door
10:54as open as possible as early as possible.
10:56Next slide.
10:58So that brings us back to our
11:01panel objectives and maybe I'll ask
11:03Collaborative Media to just take the
11:05slides down and bring us up on screen.
11:07And so I think what I'll do
11:10is I'll start by asking Alex,
11:12spend a minute just talking to us about
11:16like where do you see us headed post
11:18Pandemic with virtual care delivery?
11:20Is it going to be here forever?
11:21Is it a, is it a, you know, passing fad?
11:24But we even recognize it five years from now.
11:27What are your thoughts Just
11:27sort of kick us off?
11:30Great question. Nobody knows.
11:31But I think we can go back to nursery rhymes,
11:34which is we're trying to put Humpty Dumpty
11:36back together again because everybody,
11:38including all healthcare consumers,
11:39sort of scattered to the winds.
11:41All of us have personally changed our
11:44habits and all the way from just staying
11:46out to engaging in very different ways.
11:49And so cost of entry is really different.
11:52And we're trying to get
11:53people in on their terms.
11:54So we have to make it easy
11:56to find a doctor digitally,
11:57to schedule a doctor digitally,
11:59and then give small,
12:01medium and large choices for how to engage.
12:03Do you want a chat bot?
12:04That'll just be a symptom checker.
12:06Do you want to call a nurse hotline?
12:07Do you want a virtual visit?
12:09Do you actually want to come into clinic?
12:11Do you just want to go to urgent care?
12:12So I I think that's here to stay.
12:14I don't think we.
12:15Know where it's going yet because
12:17none of us as individuals know as
12:19patients and you as a physician we
12:21don't know where this is going but
12:23we know that it is it is in play.
12:25So we we are literally playing 52
12:28card pick up here and and it's
12:30going to be in flux for a while.
12:33Awesome Sarah opening thoughts
12:36you know I think Alex hit on a lot of
12:39the the elements which is that it'll be.
12:43You know, your example of a mall,
12:45actually let me just start.
12:46There is an interesting 1 Lee because
12:49in many ways it's, it is like a mall.
12:52Even malls don't have a single front door,
12:54right. And and so the door,
12:57like there's a main door that goes
12:59into Nordstrom, there's a mall,
13:01a door that goes into the store itself
13:04or into like the kind of main main
13:07thoroughfare where all the store,
13:09other stores connect.
13:10And so I think that's how it's going to.
13:13Be right, Alex hit on it.
13:15It's fragmented.
13:16It's kind of decentralized and there are
13:18they're going to be kind of tech enabled,
13:21digitally enabled mechanisms that connected.
13:23We know that and there will be different
13:26types of stores that are there, right.
13:29We also know that,
13:31but how they interplay,
13:32how information is shared across them,
13:34what the overall experience is,
13:36is it a really high end mall,
13:38like what kind of stores are in there,
13:40How does it, what's the look and feel,
13:42what kind of how much do you have to pay?
13:46You know, like all of those kinds of details
13:49I think are still going to be worked out.
13:52So I think we can agree on a few things
13:53like there will be different stores,
13:55so in our nomenclature it will be multimodal.
13:58It will have a variety of
14:00different ways to be accessed.
14:02There isn't going to be a single door.
14:04Google will have part of the door.
14:06We'll all own a part of our own door and.
14:10And it will be,
14:11I think to your point authenticated,
14:13right.
14:13It has to have an element
14:15of knowing who we are,
14:16whether it's fully authenticated with
14:18like a full on digital identity or
14:22authenticated sort of in a more anonymous
14:25way like just through cookies and I P
14:27addresses and those kinds of things.
14:29So I think you know to to Alex's point,
14:32we don't know exactly what
14:33it's going to look like,
14:33but certain elements will definitely be true.
14:37Yeah, I mean it's interesting you
14:39as you extend the metaphor, well,
14:41first of all, the pop up shops in the
14:43middle of the mall might come and go,
14:46but in fact the mall might look
14:48very different for Sarah when
14:49she enters and it does for Lee
14:51because with hyper personalization,
14:53especially based on the level of
14:55authentication you've offered
14:56at the time of your visit,
14:58the mall might, you know,
14:59really look different to you.
15:00And and maybe for me,
15:01Nordstrom's is tiny and Best Buy is big
15:03and maybe for you it's the opposite.
15:05So I I think.
15:06What we're what we're trying
15:08to lay the tracks for,
15:09which I agree with Alex
15:11just doesn't exist yet,
15:12is can we create a digital
15:15experience for patients that feels
15:18as concrete as walking into a mall,
15:21looking at the little billboard
15:22that tells you where all the stores
15:24are and navigating your way around?
15:27Or are we going to not be able
15:29to achieve that and and it'll
15:32feel either more generic.
15:33Or more confusing because right now it's
15:35I I think we all agree it's awfully
15:38confusing for patients and providers.
15:40And so my my hunch is it's,
15:42you know, the,
15:43the car I drive today looks
15:46somewhat like the Model T Ford,
15:48but only on the outside.
15:49On the inside,
15:50it's a completely different vehicle, right.
15:52And it's a,
15:53it's a computer with with
15:55an engine and wheels.
15:56I have a feeling that's the,
15:58that's the right metaphor for this.
15:59The next wave is going to look.
16:01Familiar someone on the outside,
16:04but what powers it underneath,
16:06I think is a lot of foundational
16:08work that needs to be done.
16:10Do you think,
16:11Sarah,
16:12that will recognize five years from
16:14now that people will still recognize
16:16a virtual visit from what it looks
16:18like today or do you think it's
16:20going to be radically different?
16:25That's a it's a I go back
16:28and forth on this one.
16:29Partly because in some ways,
16:33in order to make an effective
16:36digital transformation,
16:39we're not trying to teach
16:42folks new things necessarily.
16:44We're trying to ride alongside
16:46intuitive ways of doing things
16:48that folks have gotten used to in
16:50other parts of their lives, right.
16:53And and so.
16:57I don't know, I don't know
16:58what the answer to that is.
16:59I think we're not trying to retrain
17:02individuals to engage with providers
17:04necessarily in a completely different way,
17:07but but we are trying to arm folks with
17:10tools that make it more accessible,
17:13more sort of navigated and with
17:17information that they need.
17:20To to get the job done right,
17:22whatever that job is.
17:24And so you know,
17:26I think it's it's probably the experience
17:29in advance of a visit is going to
17:31look very different similar to like.
17:34You know when you in the early days,
17:36you know the difference between the
17:38cab and the Uber is the experience
17:40before you then still ride in a
17:42vehicle that other people have ridden
17:43in and you get to your destination.
17:46But the the way by which you
17:48access the service,
17:49knowing you know where the car is,
17:52how far it is from you,
17:54how it's heading towards you,
17:55how you've paid, you know,
17:56all of those types of things are where
17:58it's really going to look different.
18:00And so I think that's the place,
18:01those are the places where it
18:03may be unrecognizable.
18:04But then getting to the essence
18:06of the actual virtual delivery,
18:07I think the delivery is likely going to
18:10look similar to what we experienced today.
18:14Yeah. What what do you think Alex,
18:15I was I was struck by some of our
18:17previous conversations and the when
18:18we think when we think you know
18:20sort of strictly US and and you
18:22know kind of higher margin markets,
18:23I tend to agree with you Sarah.
18:25But I wonder about India, China,
18:27other parts of the rural parts
18:29of the country where there are
18:31no providers are we going to see?
18:33A virtual visit with a chat bot
18:35or with an avatar or you know,
18:36are we going to start leveraging
18:39a I as better than nothing as
18:41opposed to compared to you know,
18:43seeing an expert at one of
18:45our academic health systems.
18:46What do you think Alex?
18:48Do you think that we're going to
18:51see massive delivery of healthcare
18:54at scale with non human elements
18:57simply because of the unaffordable
18:59nature of of delivering,
19:01you know,
19:01person to person virtual care?
19:06Thinking, thinking,
19:07thinking and it's interesting.
19:09So first, first of all,
19:10if you don't have an Internet connection,
19:12if you're in a deeply rural part of India,
19:14that it's not even an option.
19:15And I'm also thinking
19:17because my family's in Asia,
19:18I grew up in Asia and it's
19:21very different model there.
19:24And if you have national nationalized health,
19:26they of course have the incentive
19:28to deliver it that way.
19:29I thought I spent most of my career
19:32in financial services and I think it's
19:34going to have to be anchored in the one
19:37and leveraged by the other and by that.
19:39So I was at Schwab when when
19:42online trading commenced and you.
19:44Only earn the right for online
19:46digital access if you have the
19:48ability to pull the rip card.
19:50So rip for it and you know that Joe's
19:52my broker doors in that corner office.
19:54If something goes seriously sideways,
19:56I can go down and talk to Joe once I
19:58know that I I have my and in this case
20:00it would be I have my like with a physician.
20:05Then I'm totally so during the
20:06pandemic is a good example.
20:08So I knew my position I was perfectly
20:11comfortable using the portal for
20:13questions using you know virtual
20:14visits but I needed that anchor.
20:17So I think you're going to have
20:19to you always need the anchor and
20:21then what we're essentially trying
20:23to do is leverage we we have.
20:25Not enough anchors,
20:26meaning not enough physicians and
20:28providers and too many patients.
20:29So the only way we're going to get there
20:31is by scaling all the wraparound part.
20:33So I think it's going to be that
20:35combination of the the anchor
20:36is going to be the physician is
20:38going to be that primary provider
20:39and then we just need to leverage
20:41the heck out of that with these
20:43ancillary digital access mechanisms.
20:45That's great.
20:46That's that's really well said.
20:48So let me let me pivot us to sort
20:50of Section 2 now with that comment.
20:54Do you think that?
20:55Do you think that we hit a watershed
20:57moment with the rapid adoption
20:59of virtual visits during COVID?
21:01That is really fundamentally change
21:03the adoption barrier to this concept
21:05of consumerism in healthcare,
21:07which I would have to say has
21:09been talked about in meetings
21:11that I've been at for the last
21:1210 years with almost 0 traction,
21:14except in some of our disruptor competitors.
21:17You know, the Minute Clinics,
21:19Walmart Health, you know, CVS,
21:21Amazon, that kind of thing.
21:22Do you think that that this is
21:24going to be a turning point around
21:26consumerism and healthcare or do you
21:27think that the medical side of that equation,
21:31it is still not,
21:32still not ready for consumerism?
21:36What do you think, Alex? Yeah,
21:37sure. Alex, take that one. So I.
21:41So I would say that it's
21:45interesting because for for.
21:48Much of the conversations
21:49that I'm participating in,
21:50it's like did televisits get to a
21:53tipping point and we're not going back.
21:56What we observed and be curious what
22:01you Lee and you Sarah have experienced
22:03is that we saw a 300% increase in
22:06portal enrollments and people who.
22:09Would normally call, make an appointment,
22:12get their car, drive in.
22:13It's sort of the equivalent
22:14of when it was the last time.
22:16Think think about when you had to,
22:17like, drive in to a bank to deposit it.
22:20I mean, that just seems hopelessly outdated.
22:22Once you got comfortable with your
22:24financial institution taking a picture,
22:26you know, emailing the image in.
22:30I I think it's that was the the
22:33tipping point for us once we got
22:35that many people enrolled a massive
22:37inclusion in the portal and whether
22:39or not they use the portal per se,
22:42they we had a huge increase
22:44in people who said oh.
22:47I have another way of contacting
22:48my provider or my health system
22:50other than making an appointment,
22:52get my car and driving in.
22:54And by the way,
22:54I don't want to drive in anymore.
22:56And I think that was the tipping point.
22:59And people that's the that's the
23:01the connection that's been made.
23:02How it will be continued and
23:04leveraged I don't think anyone knows,
23:06but I think everybody and who to myself,
23:08I I didn't go.
23:08I'm working healthcare and I
23:10didn't go once in three years.
23:11I had virtual visits and you know
23:13I messaged through the portal.
23:14I don't particularly want to go back in,
23:16you know if I break my leg
23:18that's something else.
23:18But I that has been the the biggest
23:22tipping point for our our patients
23:24is well there's another way to make
23:28contact outside of bricks and mortar.
23:32Sarah, I see you nodding your head
23:35vigorously. Give us your thoughts
23:37first. I really like the way that Alex.
23:40It separates, you know, kind of stratifies.
23:43How do you engage from a portal or or
23:47other engagement sort of channel and
23:50vehicle perspective relative to actual.
23:54Telehealth or virtual visits,
23:55So I do think those are different
23:58and we we saw an increase in both.
24:01We've seen sort of a sustained and growing
24:04engagement with our app for instance.
24:07That's one of the big channels where
24:09we drive engagement both in terms
24:11of registrations and engagement.
24:13I should say that has continued to grow
24:15on the actual delivery side of things.
24:18With respect to virtual care,
24:21that spiked and now has gone down.
24:24For a number of different reasons,
24:26bad provider experience,
24:28bad patient experience,
24:31a lot more friction in terms of
24:33logging in and having the right,
24:36you know,
24:36like it just added layers because
24:38we took this very,
24:39I would say substitutive model like
24:41just swap out a visit that was in
24:44person where you get all this context
24:46and you know like a much closer
24:48connection for something that is more
24:50removed without a whole lot of added.
24:53Benefit including like the payment model
24:56frankly isn't really supportive of it and
24:58there's all sorts of other shortfalls.
25:00So.
25:00So I think ultimately what
25:04it comes down to is,
25:06is there an actual improvement
25:08in the experience or not and our
25:11answer definitively was not.
25:13And so while there was a pickup from an
25:16education and sort of awareness perspective,
25:19that doesn't last forever,
25:21right.
25:21The experience actually has to
25:24improve and and so you know,
25:26we're working on some of those things,
25:27but I I think that's going to
25:30be the determiner of whether
25:32this has longevity or not.
25:34I was talking with another health
25:35system and they actually said,
25:36you know our patients actually
25:38prefer to interact with us.
25:40Either via phone or in person.
25:43And I said,
25:44well,
25:44did you make changes to your
25:46processes when you layered on
25:48technology or lead to your slide,
25:50which is, you know, old?
25:53Old incumbent company layer on technology,
25:56now you just have old incumbent company with
25:58it that's more expensive with technology.
26:00But you didn't change any of
26:02the underlying processes, right?
26:03That's ultimately what happens,
26:04right.
26:05So they we get like false signal to noise
26:07around those kinds of things that we think,
26:09oh, people don't really want
26:11to engage in technology.
26:12Oh,
26:12we haven't really overcome the barriers.
26:15In terms of driving adoption among users
26:17and the fact is we kind of haven't,
26:20not because they don't like it or because
26:22technology doesn't do the right thing.
26:24It's because we didn't change the
26:25underlying thing and that's what I
26:27think we're seeing and governance,
26:29you know, operations,
26:31clinical,
26:31workflow etcetera,
26:32those are the big things that are going
26:34to influence that and then payment
26:36of course. Yeah, we have a whole
26:37session about that at the end of today's
26:39symposium that I'm really excited about.
26:41You know, you, you triggered a couple
26:42of thoughts of me as you both made
26:44those really insightful comments.
26:45The first one is, you know,
26:47we're in the middle of this transition from
26:49a production economy to a service economy.
26:51You know, people don't want to own cars.
26:52They want to, you know,
26:53they want to leverage transportation
26:54when they need it, the banking,
26:56music, you know, you name it.
26:59And I think we're still.
27:01Mostly a production economy,
27:03we're producing visits or repairing hips
27:05or you know for dispensing prescriptions,
27:08I think hospital at home and remote
27:10monitoring and the portal engagement is
27:12starting to transition that into more
27:15of a like we're here when you need us,
27:17not we are here when it's convenient for us.
27:20But I would say that you know
27:21one of the fallouts for us,
27:22we also had massive uptake
27:24in our portal adoption.
27:25We're now like one of the leading
27:27I think health systems in Epic
27:29in terms of portal uptake.
27:30But that's led to an in basket swarm, right.
27:33The volume of communication that's
27:35coming through is just so much greater
27:38and is really challenging to manage.
27:41And you know unlike phone calls
27:42where people will just hang up
27:44sometimes if they get the,
27:46you know the message that there's
27:48voicemail for the practice,
27:49nothing stops them from uploading
27:50their in basket message.
27:51So I I do think that it is
27:53highlighting a challenge that we have.
27:55It's part of the reason why I talked about,
27:56you know the bots and the.
27:58Other mechanisms of thinking about
28:00can we can we also start to promote
28:02more of a self-service kind of
28:04functionality or at least shift to
28:06a different skilled level provider
28:08to to help address some of this
28:11other thing you reminded me of.
28:12Sorry with your comments about
28:15substitutive is well first of all
28:17I'm old enough Alex to remember
28:18when you had to go to the bank with
28:20your passbook to get money out and
28:21I think many of our listeners don't
28:23even know what I'm talking about but
28:24you literally had to bring like a
28:25passport with you and the teller like.
28:27Did like minus 50 and then gave
28:29you $50.00 and then handed your
28:31book back with your balance, right.
28:33So we're a long way from that,
28:34but I remember the first digital watches,
28:36they were just analog watches
28:38that were digitized, right.
28:39There was number new functionality,
28:40it was just a digitization.
28:43I think that's largely what
28:44we've done in round one.
28:45We digitized the in person visit and
28:47made it available in much the same
28:49way but without a lot of the high
28:52touch components that wrap around it.
28:53And it was a pretty good trade off
28:55against the risk of dying from COVID
28:57on your way to the doctor's office
28:58and spending a lot of money and gas
29:00getting to and from the doctor's office.
29:02But we're going to have to do better
29:04if we want to stay innovative.
29:07And I think we're going to have
29:09to figure out what are the parts
29:11that are best served by virtual,
29:13what are the parts that are
29:14best served in person?
29:15Can we can, we can We even jigger
29:17around the the in person pieces so
29:19that everything you can get done
29:21before the visit is already done.
29:24So your visit is really high
29:25value when you're sitting there in
29:27front of in front of the provider.
29:30But it raises the question,
29:31is digital access to care or digital
29:33care actually what patients are
29:35longing for or are they longing for a
29:38digital patient experience that starts
29:40to feel more in line with the other
29:42digital experiences they have as consumers?
29:45So let me now flip us to kind of
29:47the next segment and the final
29:49segment that we'll spend our time on,
29:51which is like.
29:52What does it mean to redefine
29:54digital patient experience Or as
29:55Alex said to me the other day,
29:57define it right?
29:58Because for many organizations,
29:59they they haven't even defined what it is yet
30:02rather than even never mind redefining it.
30:04So what's the right path forward
30:06for crafting this responsive,
30:09desirable, maybe, God forbid,
30:12joyful digital patient experience?
30:14And where is it going to come from?
30:16Is it going to come from health systems?
30:18Is it going to come from disruptors?
30:20Is it going to come from payers?
30:21Is it going to come from someone
30:23we haven't even thought about yet,
30:25NASA, you know, or I don't know,
30:28Tesla, you know,
30:29Is it going to come from
30:30some from some other place?
30:32And is it going to resemble
30:34more what it came from?
30:37You know, like, you know,
30:40like Neanderthal,
30:40you know,
30:41is it going to look more like
30:44medicine and with a little digital?
30:46Surface around it or is it going to
30:48look a lot more like shopping on Amazon
30:50but where what you're buying and
30:52selling and and moving around our our,
30:54our medical experiences,
30:56big topic.
30:58So sorry,
30:58why don't you take this one first.
31:02It is a big topic,
31:04lots of directions we could go with it.
31:05So I'm kind of thinking you know,
31:08I I do think fundamentally.
31:11There are some differences in in
31:13healthcare that you know we've
31:15got this like 2 by two kind of
31:17flywheel or we've got a two by two
31:19that we use to kind of think about
31:22the digital patient experience.
31:23But I would just say the experience right,
31:25the consumer experience in general
31:28in some industries you've got the
31:31margin structure to support high
31:34marketing spend so that you can be top
31:37of mind and in some you have lower.
31:40Margin structure and and we happen
31:42to be in that on that axis,
31:44that part of the axis right we we have
31:47very low if not negative especially if
31:49we look at the last year or so margins.
31:52And then there is sort of frequency
31:55of interaction with the user.
31:58Some industries have very
31:59high frequency of interaction.
32:01Starbucks,
32:02you know like those kinds of things,
32:03you go every single day.
32:05It's a low cost product and it's also
32:07just something that you get hooked on
32:09And so you're there every single day.
32:11There's some that are much lower.
32:14Frequency,
32:14because you only purchase them once
32:16in a in a while, right.
32:17There's like property casualty
32:18insurance is an example, right.
32:20We happen to be in both low ability
32:22to spend against marketing and low
32:25frequency of interaction in terms of
32:28our core business and what we call that
32:30internally is like the disruption zone.
32:33Now,
32:34because that means every single time
32:36you want to acquire a customer,
32:38you got to pay pay a ton of money
32:39if you want to reacquire them.
32:41You're basically paying the same amount
32:42that you would have if you were trying
32:43to acquire them for the first time,
32:45because they haven't seen you in so long
32:47anyway and and you don't really have.
32:51Though that many reasons outside of
32:54historically like the kind of the
32:56clinical interaction to have more
32:58frequent interactions with them
33:00anyway because you've been saying oh,
33:02you know either you came in for a
33:03surgery like something more high acuity,
33:05acuity or like how often can you tell
33:07people come in for your preventive care,
33:09come in for your preventive care,
33:11you know, it's like primary type stuff.
33:13So,
33:13so we're in this disruption zone and I
33:17think the role of digital is to move up.
33:20Kind of into that.
33:21You're never going to be able to
33:23spend that much more on marketing,
33:24but you are going to be able to
33:26create a personalized based on
33:28an authenticated experience,
33:30create a personalized experience
33:32that at least gets better.
33:35In terms of how frequently you
33:36interact with the individual,
33:38because you can not only anchor in the
33:40clinical, but also in nonclinical,
33:42but relevant products and services.
33:45And I think ultimately like at
33:46the highest level,
33:47that's what digital experience
33:48is trying to do.
33:49It's trying to create that
33:52authenticated personalized experience,
33:54hopefully a better one that's not just a
33:56veneer on top of a whole bunch of terrible,
33:59you know, antiquated processes and.
34:03And and do so in a way that's you
34:05know more affordable both for the
34:07system as well As for the user and
34:09provide access to you know new business
34:12models and those kinds of things.
34:13I think that's the goal.
34:15Now the question that you,
34:16the second part of the question
34:17that you asked is like where do we
34:20think that's going to come from?
34:21I, you know,
34:22and this might be an unpopular opinion,
34:24I think that we hate on incumbents a lot,
34:27right?
34:28Like everybody kind of talks about how
34:30slow we are and how old school we are,
34:32and we can't move that quickly and the
34:35disruptors are going to eat our lunch.
34:37And you know,
34:38and with things like Village Village,
34:41MD acquiring Summit,
34:42like all of the hype around the
34:44disruptive space just gets more and more.
34:47The fact is we're the only
34:48ones that have gotten to scale.
34:50And that we deliver the lion's
34:52share of care today and have
34:54the greatest breadth of services
34:56and the closest relationships,
34:58often with the largest number of patients.
35:01Now not consumers but patients.
35:03And so I think that there's
35:05a lot of value there.
35:06However,
35:07we're not going to be able to
35:09do it alone and I think the.
35:11There is a lot to be said for how
35:13we can partner both on the products
35:15and services side as well as on the
35:17technology chassis side to accomplish it.
35:19But I do think that it will come,
35:21it has to come somewhat from the IT
35:23has to and it will come somewhat from
35:26the incumbent care delivery organizations.
35:29I'm just given our relationship that
35:31we can leverage with with our users,
35:35well lots of really lot of meat.
35:38On those bones, Sara particularly,
35:41although unspoken,
35:42I think the issue of trust.
35:44We own the patient's trust.
35:46And in that regard,
35:48in some ways our lack of embrace of the
35:51modern marketing technology may have
35:53protected us in some ways from from,
35:55you know, being viewed as yet
35:57another organization trying to,
36:00you know, influence their behavior
36:02towards spend in our direction.
36:04I I do also think that there's.
36:07There's a really important concept
36:10here around pivoting away from episodic
36:13illness relationship to more of a health,
36:16Wellness or performance orientated,
36:19you know, experience so that patients
36:23come to us as a companion like that.
36:27The engagement platform becomes a
36:29place that people like to check in,
36:31see what's new.
36:31It's part of their news feed, right.
36:33We become part of their life.
36:35I do think that that's.
36:37A space that we,
36:38we probably want to try to think
36:40about entering and I love your,
36:42I love your your framing of the
36:45disruption zone as this space where
36:48you don't you they're not your customer
36:50for very long and once they leave you
36:52they're vulnerable to being picked off.
36:54And we have a low margin business
36:56and I would also argue we
36:57have an unpredictable margin.
36:58If I put out a a big advertisement
37:00to come to my hospital who knows
37:02what I'll get because I don't get
37:04to set the terms of the pricing.
37:06And so that makes the results of
37:09marketing very, very challenging.
37:10Alex,
37:11you've been in the marketing business
37:13for a long time and you've been
37:16thinking a lot about this and you
37:18committed together with your leadership
37:20a pretty substantial amount of capital,
37:21the cost of building a new building basically
37:24to build out this new digital platform.
37:26So talk to us a little bit about how you're,
37:30how you're convincing your
37:32organization that this digital path.
37:35Forward actually is the right way.
37:37It's better to build this
37:38than a new building.
37:40Talk to us about that journey a
37:41little bit and where you see the
37:43digital patient experience leading to,
37:44to bring value.
37:47Sure. I think so it started at the board
37:49level to get that kind of funding and I think
37:52about the journey a little bit differently.
37:55I don't think of it as digital versus analog.
37:58I think of it and and you both touch
38:01on this moving from transactional
38:03to relationship based.
38:04And it was exactly as you said, like coming.
38:07You get a flu shot, you leave,
38:08you get your hip, you leave, have your,
38:10well, woman visit, you leave.
38:12That's very different than a
38:14relationship built over time.
38:15And that's what all of us as
38:18consumers are looking for.
38:20It was I I think Banner got there
38:23because they realized with high
38:25deductible health plans,
38:26people are paying.
38:27You know, it's no longer free.
38:28Healthcare isn't free anymore.
38:30Not a $20 copay. Oh my gosh,
38:32it's $5000 deductible that I better.
38:34Attention here.
38:35And then somehow it clicked over to, huh,
38:38okay, If patients are behaving like consumers
38:41before they ever get to be a patient,
38:44we better start treating them like consumers.
38:46And that is if we go back to the we're
38:48stretching the metaphor too far here.
38:51But if you go back to retail, that retail.
38:53Got us there first.
38:55Oh, if you bought these shoes,
38:56then you might want those
38:58socks or whatever it is.
38:59But that is built on a relationship
39:02model and the biggest investment
39:05frankly is in your database,
39:07your customer comprehensive
39:09360 customer database.
39:11And interestingly,
39:12we have gotten the most leverage from that in
39:15something that is never considered digital,
39:17but of course now it is no
39:18one's used to landline,
39:19landline in forever,
39:20but our call centers have seen
39:22enormous increases in volume
39:24because people have figured out.
39:26So if I call in, they know me.
39:28And they not only know me,
39:29they know my husband, they know my kids,
39:31and I'm caring for older parents.
39:32And we've actually seen,
39:33just just this year,
39:35we've seen a 23% increase
39:37in appointments per call.
39:40Because while they're on the phone,
39:41they'll say,
39:42oh,
39:42can you schedule a flu shot for
39:45my husband or can I get my mom
39:47in for for a screening visit?
39:49So by demonstrating that we actually know
39:51you and and and Sarah to your point,
39:54it's not a high frequency business.
39:57So we're lucky if you know if
40:00we're interacting with them.
40:01I think the CDC says it or no,
40:03it's NH as it's average of three
40:06transactions health interactions per year,
40:08which means for many people
40:09it's much less than that.
40:10Yet that there are a lot of people
40:12with chronic conditions who are coming
40:13in 10 times or coming in none but in
40:15order to be there whenever they do show up.
40:18We need to indicate,
40:20oh, we know who you are.
40:21We remember what happened last time.
40:24You're you're pretty cranky about a
40:26billing interaction that you had last month.
40:29Oh,
40:29we we know that your insurance
40:31has changed and we have to set
40:34up that kind of if then.
40:36Relationship building the logic and I
40:38agree with with Sarah because I think
40:41the incumbents have something that none
40:44of the disruptors have which is high
40:47volume of data and comprehensive data.
40:49So it's it's just math.
40:52If you have a lot of data points,
40:54you can have much smarter algorithms that
40:57are much more likely to be accurate and you
41:00can much get much better at personalizing.
41:03And then and you're personalizing everything
41:05when somebody shows up to your website
41:06and you know the last time they came,
41:08it might have been a year ago,
41:09but they're interacting
41:10with diabetes content,
41:11then you serve them diabetes content.
41:14Likewise if they view a a Peeds blog,
41:18then you send them content on Peeds and
41:21so you're you're constantly improving
41:22that and I don't think any of these
41:25disruptors have anything close to that.
41:27So that's that's how I'm thinking about it.
41:29How do we move from.
41:31Interactions or or transactions
41:34to relationships and then I I
41:39use the the ROI model that.
41:42That points exactly what Sarah said.
41:45Boy it's it's industry number is farmer map,
41:48but it's it's roughly 15 cents
41:50on the dollar to keep a patient
41:52rather than get a new one.
41:54So huh that math falls to the bottom
41:56line pretty quickly if you're saying
41:57why don't we just keep the people we
42:00have build on that relationship before
42:01we go out and knock on the one door.
42:03So that was how we got to buy in.
42:06That's great. I mean what a what a really.
42:10What an interesting story and,
42:11and how interesting too that the consequence
42:15of the relationship can can be that the
42:18services being delivered are now no
42:20longer delivered just to individuals.
42:22You're really delivering services to
42:24their social network, their husband,
42:25their kid, their their uncle,
42:27whatever it is that you're you're getting
42:30more than one appointment per phone call,
42:32essentially. Right.
42:32As the more you know them and the
42:35more they they they believe that they
42:37can access the services they need
42:39in one portal one point of entry,
42:42the more you can leverage that
42:44call or that relationship.
42:46It. It is a big change though
42:49for the provider system,
42:50right and it's a big change for
42:53providers to start relinquishing that
42:56level of understanding connection,
42:58personalization from the secretary who.
43:02Staffs you know my clinic versus the contact
43:05center agent who has a unpopular right,
43:08has a huge you know has a huge
43:10machine learning enabled database
43:12about my experience expertise
43:15needs preferences etcetera.
43:17So it is a big shift in the locus
43:19of control and and that that to
43:22me is another component not to
43:24underestimate right is the is the
43:26digital transformation impacts
43:28on the existing organization.
43:31Yeah, and that trust with
43:32the position it's earned.
43:33It isn't demanded.
43:34Because until I know
43:36you're at least as good,
43:38at least as safe as my beloved and
43:40trusted person in the front office,
43:43you're not going to get there.
43:45Well, it's really
43:46going to bake our noodle,
43:47I would say is even beyond that, right?
43:49There's. There is that relationship with the.
43:53There's sort of like the autonomy and
43:56the relationship with the person who
43:58knows you as a clinician and your front
44:00desk and whoever manages your practice.
44:03There's also sort of if you blow that out at
44:05the macro level for the system as a whole,
44:07the system may not be the deliverer
44:10of all the care period even, right.
44:14And so and there is an
44:17increasing decentralization of.
44:19And distribution of where care is
44:21delivered and we talked about those,
44:24those disruptors out there,
44:25they are delivering some care and even
44:28though one of them each individual may
44:30not have gotten to significant scale
44:32yet though with like Summit being
44:35acquired by Village and do now they are
44:36a fairly sizable entity and they will
44:38be delivering a fair amount of care, but.
44:40In general that's not the case.
44:43But taken all together that is a big trend.
44:46And so we are seeing distribution
44:49of care and and there is valuable
44:53information being generated by those
44:56as well as valuable economic sources,
44:59right.
44:59And so imagine a scenario in which not
45:03you don't fight that and instead you as
45:06an incumbent are able to essentially.
45:09Capture that opportunity to say
45:11Okay care is going to keep going
45:13to where it's going to go, right?
45:14Demand.
45:15You can only do so much to capture demand
45:17and to control it where it needs to go,
45:19where you want it to go.
45:20At some point it's going to
45:21go where it's going to go.
45:23And instead let's create an
45:24economic model around that,
45:26that demand going wherever it wants
45:27to go that works for us and capture
45:29the data from it in a meaningful
45:31way within the mall, right.
45:33The mall is not just about our own services.
45:35The mall is about.
45:36Pop up shops and other things
45:38as you described it, right.
45:39So I think that's even another layer
45:42of sort of change management and just
45:45understanding of what's going to happen
45:46that we need to get comfortable with.
45:49Yeah. And and Sarah,
45:49I think we have about 5 minutes left.
45:51So I'll make one comment and then I'll
45:53give you each an opportunity to sort
45:55of make some some closing remarks.
45:57I think there is a battle for
45:59the eyes of the customer,
46:00you know there's that.
46:01The battle that Google has one of
46:03having the eyes of the browser,
46:05right it's it's the starting point for,
46:07you know for for 90 plus
46:09whatever percentage of searches.
46:11So how will we figure out how to play
46:17in that space with some of these
46:20disruptors in a way that benefits our
46:23patients but doesn't put us at risk
46:26of being disintermediated and then
46:28feeling like we are actually losing?
46:31The relationship,
46:32so how do we share the relationship?
46:35How do we have a a distributed loving
46:39relationship with our patients
46:42where the data flows with the
46:44patient wherever they go, right.
46:47We not, we're not being,
46:48it's not concealed from us these
46:51other healthcare interactions,
46:53but it's designed to be seamless so
46:55when they do go to you know an urgent
46:57care clinic and then come to us.
46:59We still know them and we know
47:01they've had that event and that
47:03I guess relies to some extent on
47:05real true data interoperability.
47:07And we're not there yet even though
47:09we have legislation that auto have
47:10created that we're clearly not
47:11in that place yet.
47:13So I guess I would say let's end with,
47:15I'll start with Alex first.
47:18You have your magic wand.
47:19You get one major change in the
47:21healthcare system that you think will
47:23enable us to be successful in this journey.
47:25What would you change if you were
47:28granted temporary authority to
47:29make one major sweeping change?
47:31Well, Lee, you and I met at the Health
47:34Management Academy and everybody
47:36there was wailing on the EMR vendors.
47:40I I do think that the two largest,
47:44we they will remain nameless,
47:45but they deliberately design
47:47themselves to be walled gardens
47:49they don't want to share and until
47:51we demand that they get over that
47:54because that that's the superhighway,
47:57it's sort of and again I come
47:59from financial services,
47:59there's you know there's
48:01federal credit ratings,
48:02I mean there's credit ratings
48:04that everybody share.
48:05Does it matter for your Visa or
48:06MasterCard or which issuing bank is
48:08everybody wins by sharing that credit
48:10rating until we get to that place I
48:12think it's going to be very tough.
48:13So but it's something we're going
48:15to have to demand and I'm guessing
48:17both Sarah and I are are party to
48:20repeated grumpy conversations with
48:21our vendors to try and like what
48:23the heck can we just make this easy
48:24not hard and it doesn't have to
48:26be custom they shouldn't standard
48:29awesome. Thank you Alex for
48:30that comment and all of your
48:32comments so far on the panel.
48:33Sorry, I'll turn to you.
48:36Amen to everything that Alex just
48:39said and I would say specifically
48:41around enabling identities that
48:44can that can federate to third
48:47parties and a healthy ecosystem.
48:49That's really the big, the big
48:52specific ask that I would have is Okay,
48:54you want to build every feature under
48:56the sun that's clinically related
48:58and sort of around a transaction
49:00you still need to let me on.
49:02Or let us as health systems sort of
49:05own that Federated identity that
49:07can partner and can be built on a
49:10set of like functional AP I's that
49:12that share information at the right
49:14level of granularity and you know
49:16we can we can really work with it.
49:18So that would that would be my big ask.
49:21The other one would be much more of an
49:24internal one which is that you know.
49:27How we can all organize around
49:30sort of standardized,
49:31modernized processes and
49:33operations internally within
49:35our within our organizations.
49:37Because you can't layer technology
49:39onto a ton of variability.
49:41And so that would be another thing
49:43that if I could wave my magic wand,
49:45that's what I would
49:45do. Sarah Sarah cheated by having two wands,
49:49not one, but but that's OK because none
49:52of us actually have that magic wand.
49:55Terrific session.
49:55Thank you both so much.
49:57I think this was really inspiring,
50:00triggered a whole bunch of new thoughts
50:02for me as I think about this space.
50:03And so, thank you so much.
50:05And with that,
50:06I'll wrap our first panel.