Episode 26 : Feet on the Ground, Head in the Clouds:

SFTS-Lee Schwamm: Audio automatically transcribed by Sonix

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Intro/Outro:
Welcome to Smart from the Start, presented by Care.ai, the Smart Care Facility, platform company and leader in AI and ambient intelligence for healthcare. Join Steve Lieber, former CEO of HIMSS, as he interviews the brightest minds in the health provider space on truly transformative technologies that are modernizing healthcare.

Steve Lieber:
Hello, and welcome to Smart from the Start! I'm your host, Steve Lieber, and it is my pleasure to bring to you a series of conversations with some of the sharpest minds in health information technology. We'll discuss the smart directions healthcare companies and providers are pursuing to create smart care teams. Today I'm joined by Dr. Lee Schwamm. Dr. Schwamm is Associate Dean for Digital Strategy and Transformation and a professor for Bioinformatics and Data Sciences at Yale School of Medicine, and he is Senior Vice President, Chief Digital Officer for Yale New Haven Health System. In this role, he's leading the development of a new digital health strategy for the school and the health system, and serves as an influential physician, leader and agent of change for the adoption of virtual care and digital enablement throughout the enterprise. Before joining Yale, Doctor Schwamm was at the Mass General Brigham Health System in academic and administrative leadership roles and a professor of neurology at Harvard Medical School. Welcome, Doctor Schwamm.

Lee Schwamm:
Welcome, Steve. It's a pleasure to be here.

Steve Lieber:
I am really looking forward to this conversation because of the multiple roles that you have. We want to first talk about digital health strategy. So you teach it, you develop it, you implement it, you're deeply involved in it. So let's talk about developing and implementing digital health strategies. What are some of the key things that our listeners ought to know about that part of sort of the upfront work that needs to be done as we move forward on this journey?

Lee Schwamm:
I wish I could distill it all into one sentence, but let me aim for a few really core principles and strategies. I think maybe the first concept is feet on the ground, head in the clouds. You can't design these kinds of digital enablements at 30,000ft and not be deeply engaged with the actual methods by which care is delivered. I think we have made a fundamental blunder in the design and execution of electronic health records because they work great from 30,000ft, but what they do to the workflow in the direct patient provider interaction has been very distorting and has caused moral injury for many physicians who spend more time staring at the computer screen than at the patient's face when they're in a room with just the two of them. I mean, your grandmother and mine would have said nothing is ruder than to stare at a computer while someone's trying to tell you their innermost feelings and fears. So we got to get that right. So, I am a practicing stroke neurologist. I practiced my entire career, and my entry into digital health was to develop and scale Telestroke, which was a digital reconstruction of an acute stroke encounter so we could deliver advice at a distance and treat patients with time critical disease. And I've kept my practice from really that fundamental reason that you have to walk in the shoes of the people who will use your product to make sure that you are delivering an excellent experience, not a mediocre experience. The second big thing I would say is fundamentally, it is all about value and adoption. You really can't get much value without adoption, but adoption without value is just letting a thousand flowers wilt.

Lee Schwamm:
So the truest measure of your success is that everybody loves your digital offering and would storm into your office if you took it away. If you have a digital offering that you think is really cool and is, you know, just the cat's meow, but only a handful of people use it. And if you turned it off and no one noticed, like that's not value. No matter how elegant it looks to you, that's really where we have to be at this. We have to marry these sort of ideal notions of digital enablement with the sort of sort of pragmatism. It's got to work for real people in real life. And then there has to be financial sustainability. Gone are the days in healthcare where we can do things because it's fun or because it's think it adds some quality, but it costs us a lot of money that we never recover. We have to tie these initiatives to the core initiatives of the organization. A lot of my colleagues who have a separate strategic plan for digital, and I always say no, there is no separate strategic plan for digital. The strategic plan is the enterprise strategic plan. You infuse that plan with the art of the possible. Your job is to digitally enable what the enterprise has identified as its strategic objectives. Then, you don't have to worry about the budget for those interventions. They're baked into the deliverables, and they are a fundamental part of the strategy. You never want to be a secondary thought in this process. You want to be helping to shape the art of the possible, and then delivering on that promise so that your health system is successful.

Steve Lieber:
I think that this last point is outstanding in terms of the statement you made, which is there's not a separate digital strategy. It is the strategy because we certainly recognize that digital technology is woven through everything. And so. It's just a natural progression of thinking that I think you've hit on there, that it's totally integrated. But if you think about it separately, you're sort of a second thought. I really like the way you pointed that out.

Lee Schwamm:
Let me add two brief things to that. One of the byproducts of this, which ideally is a very disciplined approach to implementation, is that you start to force upstream a change in the way your healthcare executives think about projects and project design. They can't just have their head in the clouds with no feet on the ground. They have to understand the implications of saying, we want X; we want to modernize, you know, access. Okay, well, then you need to tell me who's in the tent, who's out of the tent, who gets the tool, who doesn't get the tool. How does that strategic objective actually play out in real life? That brings a level of disciplined thinking to the enterprise strategy, which it sometimes lacks in healthcare. And I think that makes the organization healthier. The other comment I would make, or the observation I would have, is that when I studied the whole implementation of the Toyota Lean methodology concepts, one of the things that struck me the most was not so much the changes that happen in the factory, because you control everything in the factory, and it's a very interesting and important approach to improving the quality and the production concept.

Lee Schwamm:
But actually, what was most interesting to me was they then had to go out and work with all their suppliers to bring them into the just in time production model. So it's not enough to do your own thing in your own domain. You then have to work upstream to all your suppliers, whether that's the board, your clinician, stakeholders, you know, the joint Commission and get them aligned with this mission. Because if they're not aligned with your production process, you won't be maximally successful. So it's really a tremendous focus on business engagement. And one of the things we've done at Yale with our information technology team is we've transformed it into what we call digital and technology solutions. We're very focused now on solutions, and we're organized into experience pillars. So we have a patient experience, a care team experience, an employee experience, and a researcher and analyst experience. And we try to align our product delivery through the lens of that experienced user who is trying to have an integrated and seamless connection with us.

Steve Lieber:
We loaded a lot there that I again, kind of like you in the opening. I wish I could get all this all in because you really want to touch on the clinical teams in terms of how you're bringing them into the conversation, the end user, so to speak, the person that all of this is being done for, how they're intersecting with it as well. So, let's start with the care team. And you did you made the comment about the way that EMRs were originally developed and the shortcoming to be tactful in terms of of how they were designed. So, as you're moving into, I'm sure we can safely call this a next-generation level of technology. This is more than just iterations of a previous as we move into virtual and smart care teams and such; what are you hearing from clinicians and frontline staff about what they're looking for how they're reacting to them? You made the comment. We have gotten to the point with some of our technologies that they will yell and scream if you tried to take it away, which is a long way from where we were maybe 15, 18 years ago, which was, okay, I can wait this out and retire before I have to. But so, bring us up to date in terms of challenges, obstacles, or opportunities you're sensing with the care team.

Lee Schwamm:
Yes, I think we're hearing from everybody is I want to do my job in a different way. That lets me focus on the things I trained to do and really add value in the things I'm spending my time on. Can you make the other stuff either go away or happen automatically in the background? And can you reassemble my work in such a way that I have more joy in performing it? And I think the answer to that is very much yes. I think ambient listening, powered by large language models, is a breakthrough technology that is going to infuse everything we do, and at some point in the future, we won't even talk about it because it'll just be how we do what we do. I think that's really important. Let me pause for a moment and just dwell on that just for a second. Because large language models for the first time, in my opinion, represent an opportunity for the unskilled worker to execute complex tasks simply by writing or speaking in plain human language. We've never had that before. We've had progressive approaches to that, but we are now at a point where a fairly sophisticated set of tasks can happen by voice command. Now, we had a version of that when I trained. It was called verbal order.

Lee Schwamm:
You just said. As a doctor, let's give x, y, z, let's do a, b, c. And somebody wrote it down, and somebody did it. I think that's what people want. And they want the ability to have the administrative components of tasks where they are not directly influencing the care itself to be moved into the background and taken off their plates. I think nurses feel this tremendously. I think doctors feel this tremendously, and we've got to get better and figure that out. So that's one big bucket. I think this is sort of ambient documentation. The other one is let's recombine how the work is done and where the work is done. So we all know from the pandemic you can do a lot of work from sitting in front of a computer on the beach, you know, in your home, at a second office. Doesn't matter where you are; there's a lot you can do, but there's some stuff you can't. How do we deconstruct the clinical encounter and say which parts benefit most from continuous, direct, face-to-face or pixel-to-pixel interaction, and could be done by a different role group in the same care team mix, and which parts require me to put my hands on the patient to clean and bathe the patient. You're going to be touching that patient.

Lee Schwamm:
You can't do that remotely. But that doesn't also require the level of skill of a 20-year career nurse. On the other hand, admissions and discharges. There's a lot of time spent collecting and curating that information, and the bedside nurse is often interrupted in the middle of that to go rush over and see a patient who's become acutely ill or has some other urgent need. So, both parties are being poorly served by that. So we are embarking on a nursing care redesign model, and we are thinking about how do people spend their time, what are they actually doing, and how can we recombine that to deliver not only better value for the health care system but a better experience for the nurse. How do we keep that nurse who's been working for 20 years and is ready to quit healthcare? How do we keep that nurse engaged? How do we create a new opportunity for them? How do we remotely supervise the 30% of our workforce that is brand new in nursing? They're coming right out of nursing school. We have tremendous nursing shortages. How do we shorten that flight path of getting off the runway and getting into orbit? How do we shorten that for a new graduate? By pairing them, perhaps with a virtual mentor who can be available whenever a mentor is needed, but not standing around waiting when they're not needed? So it's really about, you could call it productivity but I don't think that's the right way to capture it.

Lee Schwamm:
It's really about maximizing the value that people add when they're in an interaction, in a healthcare interaction. So that's kind of the inpatient experience at the bedside. But let's just amp that up one. Let's put a video capability in every patient room. Now when you get admitted to the hospital, your primary care doctor, if you're lucky, will come once while you're there and poke in on you and see if everything's okay. But most of the time, you won't. The hospitalists will care for you. And maybe if you're lucky, they'll talk to your primary care doc, or they'll exchange an email. What if your primary care doc could just beam into the video at your bedside? Hey, Steve, you know, I know you had the kidney stone. I'm so sorry. Anything I can do? Any concerns you have, I'll make sure that the team knows A, B, and C, right? Amazing. The pharmacist can come to your bedside virtually and say, Steve, you're going to be starting on this new, very complicated medication that suppresses your immune system for this treatment of this cancer that you have.

Lee Schwamm:
I'd like to explain it to you a little bit and answer any questions you have, and review your other medicines with you to make sure that none of them have a bad interaction. All these things that we don't do because it's just too expensive and logistically complicated to move all the moving pieces around and make them be in the same room at the same time, those start to go away, they melt away, and then we move up the value chain to the consultants. This every hospital has to have a team of neurologists around in the hospital every day. When I was at Mass General Brigham, we proved the answer to that was no. You could have neurology consultation in any hospital in our network. By the same team of highly trained research-published cream-of-the-crop neurologists serving our entire network of community hospitals, that was better value for the patient was better value for the health system. And we even showed that we could shorten the length of stay because you get an expert the first time and you get the expert early in the course of the care. So those are some examples of how I think we're going to be able to leverage technology to modernize the business cycle.

Steve Lieber:
Again, kind of harking back to the early days of EMR. We ran into a lot of resistance. Are there similar sorts of issues of resistance? I mean, you articulated extremely well the opportunities and the upside potential, and certainly workforce issues are paramount in everybody's minds in terms of burnout and turnover and that sort. What are we having to worry about in terms of resistance to these technologies?

Lee Schwamm:
Yes, absolutely. And we would be foolish to think that there won't be. And I wouldn't even say resistance. Let's just call it concern, because resistance sort of implies that they are obstinate or that they're sort of acting out of purely self-interest. I think we have to make sure that what we do is safe and effective. We have to compare that to our current human-based systems, which we know are highly fallible. Let's not kid ourselves that we're not comparing automation to perfect. We're comparing automation to random, hopefully, good outcomes with well-meaning people. But that is not a high reliability system. So, we have to look at the workforce and what their current skill set is. If we can't upskill the workforce to help them take advantage of these tools, we run the risk of creating a new cadre of jobs we can't fill and losing a bunch of employees who can no longer be effective for us. That's bad. So, one of the reasons I'm so excited about these large language models is because they represent an opportunity to be an interface between our workforce and a greater degree of automation and capability that will help bridge that gap. We can use those tools to actually train this next generation of workforce to engage more effectively with their work. So I'm optimistic we can overcome that. But I will just be very transparent right when I grow up. As a kid in New York City, I lived in an apartment building. There was an elevator operator, and they would manually, you know, you remember this, I'm sure because we're the same age, they would guide your elevator to your floor, and if they were really great, it would just perfectly match when it landed. And if not, they had to go up or down or, you know, a little bit up and down.

Lee Schwamm:
Then we got a fancy new automatic elevator. We still had an elevator, man. He came in. He would push the floor for you to your floor. And then, over time, it became clear that didn't make sense. Right? So there are some elevator operators who won't be doing that anymore, right? There's going to be stuff in back office processing that these tools are going to do largely unsupervised or with many fewer supervisors than they currently have. And so I think we have to be cognizant of the fact that it is incumbent on us to upskill the workforce and to allow them to continue to transition with us as we implement. So, we cannot try to swallow more innovation, automation, disruption than the organization can tolerate. So, pick your battles carefully so they are not battles. Find those sweet spots where the workforce is yearning for change, not just you. And I think that's where you really succeed. That's why nurses have to be leading the nursing care redesign model, and we are enabling them. There is no separate digital strategy for virtual nursing. There is a nursing strategy which digital will support. That's our job, Steve. If we come in with these tools and say, guess what? Tomorrow, here's how you do your job; we will all fail. We have to say instead, hey, Sarah, John, Fred, how could your work be done better? What are your ideas for where there's low-value work? What would you do if you could design this magically to make it better? And then you can say, wow, we can do some of that with you. Not for you, but with you.

Steve Lieber:
Yeah. That's outstanding. The answers you just gave there really are very applicable to our wrap up question, but I'm going to come back and ask for one more piece of advice. So, you know, our listeners or folks like you and all. And so from your experience and all, an essay in the past number of minutes, here are a number of key pieces of advice. But one takeaway here, in terms of what you'd like to leave with the audience.

Lee Schwamm:
I would say be part of the we, not the them. Walk the floors, sit in the offices with the care teams, watch the care being observed, demonstrate your interest and your ability to listen to those individuals on the front line who are delivering the care so they feel your part of their team. Because once you're part of the them in the corporate office, mistrust abounds and resistance increases. So be a we, not a them.

Steve Lieber:
That's just spot on. I really do like that. We've been with doctor Lee Schwamm from Yale New Haven, and had a wonderful conversation here about a number of key topics. Lee, I really do want to thank you for your time today.

Lee Schwamm:
Well, it's been a pleasure, Steve, and happy to come back anytime.

Steve Lieber:
And to our listeners, thank you for joining us. I hope this series helps you make healthcare smarter and move at the speed of tech. Be well.

Intro/Outro:
Thanks for listening to Smart From The Start. For best practices in AI and ambient intelligence, and ways your organization can help lead the era of smart hospitals. Visit us at SmartHospital.ai. And for information on the leading smart care facility platform, visit care.ai.

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