Welcome to Digital Health Frontiers, where we explore the cutting edge of healthcare technology, policy, and innovation, hosted by Mike Brandofino, President and COO of Caregility. Today Mike is joined by Peter O’Connor, the Director of IT for Inova’s Eastern Region Development Program which includes two new state-of-the-art hospital campuses totaling over 1.5 million square feet, as well as a new ambulatory facility that will include a full-service emergency room, ambulatory surgery, imaging services, a family medicine center and medical offices. Peter leverages his 33 years of technology design, implementation, and consulting experience to ensure that clinical process is enabled by technologies that meet the immediate clinical need, fit within Inova’s clinical IT ecosystem, and support the health system’s long-term digital strategy. Today Peter joins Mike to share insight into his approach to patient room design at Inova.  

Mike Brandofino:

Hello everybody. Today with me, I have Peter O’Connor from Inova to talk about some of the experiences that they’ve had implementing virtual care within their health system. Hey Peter. Thank you very much for joining.

Peter O’Connor:

It’s my pleasure, Mike. Thanks for having me.

Brandofino:

Can you just describe the health system for the audience, so they get a little idea of what you guys are up to?

O’Connor:

Sure. Inova is Northern Virginia’s leading not-for-profit healthcare provider. So our mission is to provide world-class healthcare every time, every touch, to every person in every community that we have the privilege to serve. We’ve got about 20,000 team members that provide more than two million patient visits a year. We have an integrated network of five hospitals, approximately 2,000 beds, and lots of primary and specialty care practices. And interestingly enough, we’re the fourth busiest emergency room in the nation, so our hospitals are recognized with the US News and world reports. In fact, our Fairfax Hospital is the number one hospital in the DC metro area. We’re in the top 50 in neonatology, and top 20 in the nation for OBGYN.

Brandofino:

So, can you talk a little bit about your role? I think it’s a little unique, although I think some health systems are starting to put some focus around this. But can you talk a little about your focus and your position?

O’Connor:

Sure. It’s been really fantastic and it’s been a role that I really feel like my career – which is going on 33 years – I feel like the last 30 years have really prepared me for. We have a unique team at Inova for design and construction. I’d say we have a bit of a dream team. We’ve got our own engineers, architects, former contractors, & Clinical and operation experts. So, in my almost now 40 years I’ve never seen in healthcare design and construction an owner’s team with this level of experience.

So my role is pretty interesting. I bridge the gap between design and construction, IT, clinical engineering, and operations, which are typically siloed in a design process. The Inova leadership team saw an opportunity to have somebody with experience in all of those bridge the gaps and translate clinical process and what it’s going to look like in 2028 into enabling technologies and then turn that into something that can be procured and also built.

Brandofino:

You know, it’s such an interesting role and I wish more health systems would have that. So many times we’ll be talking just to the clinical side and then then when you start talking about implementing any kind of solution then either the technical side or even the facility side comes in and goes “oh, no, no -you can’t do that because of this,” or “hey, did you know there’s a lead plate in the wall next to the room that you wanted to do that Wi-Fi in?” So, I think it’s really an interesting role.

What’s it like to bridge that gap and pull those people into the same room, so to speak?

O’Connor:

It’s honestly exciting. It’s knowing that we can pull those people together in a collaborative space and brainstorm and learn from each other and really feed off of each other’s energy. It’s one of the reasons I came to Inova. I’ve had the privilege of working with lots of hospitals throughout my career in the architecture and engineering world and I’ve found that a lot of — if you could imagine folks swimming in a pool — that a lot of times it’s exactly what you said. Biomed may be going one direction, clinicians may be going in another, IT may be going another, and everyone’s swimming in a different direction. At Inova, I found that everybody was swimming in the same direction and with the same objectives and my role allows me to lift those little buoys in between the swim lanes and have everybody kind of work together and go in that same direction and see what other people are doing and leverage those experiences and come up with some really innovative solutions.

Brandofino:

How much does the patient experience fit into what you guys are trying to do?

O’Connor:

Patient experience is obviously essential. From my perspective, from a technology perspective, we want that technology to be seamless, and transparent, and to always enhance the patient and caregiver experience. When that technology becomes front-of-mind, kind of replacing healing and care front-of-mind, we’ve done something wrong. We have a tremendous responsibility to design places that heal, places that – on somebody’s worst day, whenever they feel they’ve lost all control over their environment – use technology as one of those ways to help them find some level of control and normalcy through access to information, access to education, control over their environment, access to the amazing bedside team, and make that as simple as possible for the patient. That patient experience and bringing some level of normalcy and control to a very hectic time in their world is critical for us.

Brandofino:

We spend so much time focusing, even as Caregility, on the clinician, primarily the nurse because they’re the ones using the technology the most, but we can’t forget the patient experience and what they’re going through. So that’s great that you guys have focus on that.

O’Connor:

Our IT and nursing leadership consistently remind all 650 of us IT teammates that were part of the care team. They encourage our IT team, whether you’re in leadership or you’re an analyst or you’re in the service side, to round just like the clinicians do. So, spending time on those various units gives you that real perspective of the patient and the teammate experience. Simply put, our mission is to get the right information to the right people at the right time to make great decisions.

Brandofino:

Sure. Well, stay on the clinical team. We have we have a chief nursing officer and some nurses on staff and I constantly get, “But Mike, you don’t understand what the nurse is going through in the room at the time. You’ve got to consider that.”

What insights are you getting from your clinical team as it relates to helping them in the day-in-the-life of a caregiver?

O’Connor:

We’ve had this pretty extensive design process for our new Eastern region expansion, which is two full size hospitals, full medical campuses, a Cancer Center, a specialty care center, about a million and a half square feet. So over the last two years, we’ve had thousands of hours of clinical input. We even built full-scale mock-ups of patient rooms, treatment rooms, ORs, imaging spaces, even the team stations to ensure that those designs work within that clinical workflow.

But, also, they were prepared for future technology and clinical processes. So having the clinical team come into, let’s say, a hybrid OR and they can move all the pieces around and they can mock a code or they can mock a certain procedure – gives us insight that you can’t get out of looking at a floor plan, or even can’t really get out of some of the 3D modeling. It’s just nothing beats walking into a room that’s fully constructed, and they can move things around, which is fantastic.

I would say that one of the keys to our success has been that our projects are led by a clinical team. It’s a million and a half square foot Eastern Region Expansion led by a clinical team. Heather Russell is our VP of Eastern Region Development. Eric Miller is our director of Eastern Region Development. They both have extensive clinical backgrounds. They’ve been instrumental in ensuring that the clinical voice is not only heard, but also that the clinical process is understood by everybody involved – all of us internal experts, the design construction and architecture teams. So having a construction project led by clinical operations and supported by in-house industry experts has really been our secret to success and taking that clinical voice and translating it into something that can actually be built.

Brandofino:

That’s great. Having the buy-in it is going to help. What are your biggest challenges? Sometimes the challenge is just people having an aversion to change and others are just that some of these hospitals are old or challenging to change, especially with patients in rooms and it’s kind of like changing the chassis on the car while it’s moving.

What are some of your biggest challenges?

O’Connor:

I guess from a change perspective, you’re talking about physical change from an infrastructure, but also change from a culture and thought process perspective. The good news is our CEO, Dr. Steven Jones, reminds us all – and this is in all of our Web leadership meetings, in-person leadership meetings, any time that we’re fortunate to spend with him – he reminds us to challenge the status quo and always ask why. That spirit of unrestrained curiosity has led us to either reevaluate and reconfirm current processes or quite often, it’s been the catalyst for change and to explore the why-nots and make them real. So, from a culture perspective, we are well positioned to embrace change, look for change, ask for change from the clinical level through the IT level, and design, and construction, and facilities – you name it.

But some of the challenges that we have is taking all of that that we’ve envisioned for change and documenting it well. When you’re looking at a million and a half square feet of design and you’re trying to coordinate architecture, MEP, medical equipment and technologies, security, AV, there’s a lot of moving sites or moving parts for three sites that we’re building. Traditionally projects like this, the lack of decision or direction is usually the biggest challenge. Fortunately, with our clinical leadership team on the project that’s not been a challenge really. It’s making sure that all those voices and all those hours of work and working through the clinical processes and translating that into a built environment gets documented well and gets constructed the way we expect it.

Brandofino:

That’s great. It sounds like the executive team is close to these projects and provides you that aircover that you need. That’s great to see. We’re seeing some customers who lack that kind of centralized support. You have pockets of folks fighting to try and get the attention, the funding, and get their program projects through. It seems like you guys have kind of centralized that and have the executive team providing overall air cover.

O’Connor:

We do. Our executive team, our C-level team, knows about every square foot of the new construction. Heather, being a nurse herself and a senior member of our core leadership team, that visibility and that voice – anything that we need, decisions to be made, executive direction – it’s one phone call away with Heather. And from an IT perspective, our Chief Digital Information Officer and our Chief Technology Officer are highly engaged as well as all the senior members of our networking cybersecurity infrastructure team. So, from day one, everybody’s been engaged in these projects. Throughout my career – as I’ve mentioned, I’ve worked on other projects – I haven’t seen that level of engagement. As you said, I’ve seen pockets of engagement. I don’t think I’ve ever seen the systemwide level of investment of time, energy and, direction in projects like this.

Brandofino:

That’s great. In projects this scale and size, you have multiple vendors and partners – we like to consider ourselves a partner because we’re in this for the long haul with our customers.

What are you looking for in vendors and partners as these projects progress?

O’Connor:

The scale of what we’re doing – we’re adding a million and a half square feet, two new campuses, but we also have five existing campuses and 7,000 nurses and so you’ve got a very complex existing enterprise environment and then you’re adding on to it with new construction and innovation. How do you take some of that new technology and put it into the existing environment and how do you take ideas that we want to do today and translate that into something in 2028?

What we look for are industry segment leaders that want to collaborate. Folks that are innovative themselves. They’re looking to the future. We want partners to have that same “why or why not” conversation with us and that we can have with them. It is truly that partnership of collaboration. Folks that fit into the Inova culture, that have that mindset. We need partners that are willing to work with other partners and create enhanced integrations that enable that seamless experience that I identified earlier. Without that type of collaboration and partnership – and as you said, in for the long haul – it’s not going to be easy. We’re going to be pushing and pulling on each other. But I’m a firm believer that sometimes you go through a little heat, and you create relationships. The strongest bonds are formed with heat sometimes and so you get a great partner that will get in the trenches with you and help figure this out. And then everything just seems to work out for the best. So, we’re fortunate to have wonderful, wonderful partners.

Brandofino:

That’s great. So, the buzzword right now in healthcare is Virtual Nursing. Hybrid care is another term for it. We’re actually seeing some tremendous feedback. Customer satisfaction is up. Nurse retention is up because of it in some of our health systems.

How is your organization thinking about hybrid care? Is it being embraced and are you seeing any success at it yet if you’re actually going down that path?

O’Connor:

We’ve transitioned from thinking about virtual care to living it and breathing it every day. We’ve got some innovative thought leaders from our Chief Nursing Information Officer, Maggie, our Chief Health Information Officer, Dr. Kramer, and our Senior Director of Telemedicine, Steve. We have implemented an industry-leading Virtual Nurse program, which began with some basic use cases with virtual admit and discharge, patient education, patient pain reassessment. Those use cases alone have reduced bedside time by roughly 30 minutes per nurse per shift. So, you can imagine giving 30 minutes per nurse per shift back to that bedside nurse to do the things that he or she is really, you know, in their heart, they want to do. They want to deliver bedside care, right? Not be going through a lot of things, so it’s a great use to those resources and somebody that can step in virtually and assist that patient in whatever they may need.

So now, since that’s been so successful, we’re now looking to dual consent, we’re looking to case management and wound care as additional telemedicine applications or virtual care applications. So again, expanding that footprint, that technology that we’ve invested in. You guys have been a phenomenal partner with us in doing that. So just extending that program, so all of our five sites are connected back to what we consider a very innovative high-reliability Operations Center, which is our rock where Virtual Nursing, our Central Telemetry, our Central Sitting Resource Management, our Transfer Team all operate out of the same suite on one of our floors in our corporate campus. So, you can imagine all those folks are together to make great decisions about moving patients, taking care of patients, all in that same area. We’re looking at serving 2,000 beds out of a central location. It’s been pretty innovative and it’s been open almost a year now and we’ve had nothing but tremendous feedback from our nursing teams and our patients.

Brandofino:

That’s great. We love to hear that because I think we’re getting close to a time where you could just cross out “tele” and “virtual” and it is just healthcare. It’s the way we have to deliver healthcare these days. You mentioned in the partnership, the need to be able to work together.

So how important are integrations? And from that perspective, what do you think the vision is of patient experience in Inova as you go forward?

O’Connor:

I keep on coming back to that word “transparent.” Those integrations have to be what I consider invisibly critical. And today, you know, in our personal lives, we all expect context in our alerts and how we integrate with our devices and you know the ability to delineate the noise from what’s really important and the same goes for our healthcare environment. You know the EHR gives us context, the nurse call is that patient’s lifeline, the interactive patient engagement system is that medium to provide education and information, and virtual care is that reassurance that you have a multidisciplinary team ready and available to be there whenever our patients need them, whether it’s in the patient room setting or it’s in the emergency room or it’s at home.

To your point, I think it is just healthcare. It is just a different way to meet people where they are and I think so often healthcare institutions have this mindset of “you have to come to our site, you have to be in our room.” We have two million patients that we have the privilege to serve and finding the best way possible to do that in whatever environment it needs to be is really where we need to be as an industry.

Brandofino:

Something that’s been top of mind for a lot of folks — from an ROI perspective, there’s soft-dollar ROI, there’s hard-dollar ROI – how does your CFO look at some of this? Do they consider the soft-dollar ROI as well? That patient satisfaction, the nurse satisfaction. Does that play into your ability to continue to expand these programs?

O’Connor:

Oh, absolutely. So we’re always patient-first. Fortunately, we’re a very successful not-for-profit healthcare system, and our ability to reinvest in our infrastructure, reinvest in our people, reinvest in the community and programs, we’re very blessed to be able to do that. But in order to do that, we have to be operationally efficient. We have to have the volume of patients that people want to come to Inova and want to be treated at Inova. So it does come down to those soft dollars. They are really hard to put a number on or a value on, but, again, we’re patient first so having our care team enabled with the best technology, having them to do what they do best at the bedside, having the best diagnostics and ability to intervene and deliver care – it is the most important thing to us at the end of the day. If we’re successful financially doing that it just gives us the ability to do that even more in more places to more people and have better technology.

Being a not-for-profit, private healthcare institution is a really unique thing and we’re really in control of our destiny and how we apply those resources. Our leadership team has done a wonderful job with that balance of growth and reinvesting in our infrastructure and also caring for our communities and the people who are less fortunate who can’t afford care.

Brandofino:

Clearly, you guys are a leader, and your role alone. What to me is unique in the space is really taking this seriously and putting some resources around it that really understand how to move these projects forward.

So for those health systems that are watching this, that maybe haven’t gotten started yet or had some stop/starts, can you give them a nugget of advice that can help them on their way?

O’Connor:

I think for us it’s been creating a culture where people are open and willing to listen to what doesn’t work and have the courage to ask “why not.” Having executive leadership supporting change and having partners that can collaborate and not be afraid to add a couple of destinations on the road map for us is critical. I think that the key to our success, it really does come down to – at least for me – it’s culture. It’s having an environment that lets us explore and innovate without being so adherent to recorded direction. We’re always asked the question or encouraged to ask the question “why” so for me, it’s been a culture thing.

You would think that this is all tech and innovation and being able to try different things. If you’re not in an environment that supports that, all the technology in the world is not going to help you. So it’s having the culture. Change starts with the culture.

Brandofino:

You speak my language. I always have said technology for technology’s sake is just not the way to go. If you can get the buy-in, if you have that culture that is willing to try things and fail fast, right? Not everything is going to work the first time, but if you’re willing to fail fast and try new things, I think you end up accomplishing a lot more than those who kind of wait for that perfect thing, whatever it is.

O’Connor:

Absolutely. The ability to do pilot programs and having partners willing to help us out and see what works and what doesn’t work. In an environment where you’ve you’re confident and you’ve got the confidence in your leadership team that you can try and fail and then you get up and you try again and this works. Having that environment is fantastic. We have a lot of exciting things ahead of us and we look forward to building an infrastructure where we have virtual health in every patient room. All of our new construction, we’ve got it planned and we’re working on processes and plans to move that into existing care spaces today. So you just have to position yourself and look towards the future and the future is, to your point, just healthcare. It’s not virtual health, it’s not inpatient healthcare. It’s just healthcare.

Brandofino:

Well, Peter, thank you very much for taking the time to share your experience and your story with hopefully a lot of healthcare systems that will learn from this. I really appreciate it and thanks for joining.

O’Connor:

Thanks for having me. Have a wonderful day.

Welcome to Digital Health Frontiers, where we explore the cutting edge of healthcare technology, policy, and innovation, hosted by Mike Brandofino, president and COO of Caregility. Today, Mike is talking to Jonathan Witenko, the system director of virtual health and telemedicine at Florida-based Lee Health. Holding multiple certifications from CHIME, Microsoft, Cisco, and others, Jon helped design and implement telehealth at Lee Health in 2014 with inpatient stroke and over the years grew the program from one project to a systematic rollout of inpatient, outpatient, ambulatory, and population health programs. Lee Health is a great example of how virtual care has evolved from a nice-to-have to a critical application. In this episode, Mike talks to Jon about this transformation along with the responsibilities and new challenges it brings to healthcare.

Mike Brandofino:

Hi everybody. Welcome to Caregility’s podcast. Virtual care has been around for many years, but recently it’s kind of gone from nice-to-have to a critical application, and I’m happy to have with me Jon Witenko, who drives virtual health for Lee Health system to talk about that path, that journey, if you will, from nice-to-have to critical. Thanks for joining us, Jon.

Jon Witenko:

Absolutely. Good to see you, Mike.

Brandofino:

So if you could share with everybody, how did it start? So when virtual care started for you and Lee, what was it like? What were the challenges you were facing and how many people were involved?

Witenko:

Yeah, absolutely. So we started virtual care actually in 2014. It was a one-off project. We had a group of neurologists, excuse me, that were doing stroke care. And geographically, one of the challenges is there’s non-value added time of driving from hospital to hospital. So ideal state, we’d have a neurologist sitting there 24/7 twiddling their thumbs, waiting for patients to come in and have a stroke. Well, the reality is it’s not cost-effective. So we have one physician covering four or five different hospitals, and depending on where the patient comes in, they may have to drive from facility to facility. And this is the model that’s existed for a hundred years, as long as we’ve had hospitals. Well, contractually we’re facing that issue of the windshield time, as they call it, of driving from hospital to hospital. And the patient, all the time, has this block in their brain, a brain bleed, and I’m not adding any value just sitting in the car.

So can you do something cool to help that? Can you teleport me? Can you do something? And so that’s where for us, telehealth was part of everybody back in the day, 10 years ago was, alright, you either start with behavioral health, the clear Baker Act, or you start with stroke. And so for right, wrong, or indifferent, we started with stroke and I started working with Dr. Carracino at the time who was our neurologist and I think maybe had been our CMIO, I’m not sure his role, but was a neurologist taking call and said, all right, what does this look like? And I said, well, I am not a clinician. I’m an engineer by trade, a computer engineer, so tell me what you need. And he said, well, for me to do an assessment, I need look in the patient’s eyes, see their pupil dilation, hear their speech, do they have a tremor? Are they coherent? And then a little bit of a physical assessment. So they have to squeeze and range of motion kind of things. Okay, so do you need to physically touch the patient?

He said, other than the squeeze and there’s a stroke scale, but somebody else in the room could do that. Okay. I said, well just get the doc on site to do all that stuff. He said, no, that’s why I went to neurology school. I’m specifically trained and I have to make an evaluation. Do I give this patient TPA this drug or not? I’m the only person, it has to be a neurologist that gives that order. Okay, so let’s figure out, can we do it with a camera and what does that look like? Let’s just put a webcam in the room. Again, this is 10 years ago and there wasn’t a lot of folks doing it. And so we really started to look at who’s building a telemedicine cart, if you will. And there were a couple of big-name vendors, but it was really cost-prohibitive. It was about $80,000 a cart for a beautiful touch model. And we said, well, we don’t have that much money. We have about a hundred grand and we have five different hospitals, so we can’t divvy it up and get it in the car and drive it.

So we ended up buying the technology. I built the carts myself in my garage and we put it out there and then crossed our fingers and said, okay, does this work? And Dr. Carracino came in, he was actually the first one to use it and he came in one day and he goes, Jon, great news. Last night, I’m sitting at home and the phone rings. And he goes, well, it’s at Gulf Coast. And at the time they couldn’t get paid for telehealth. He said, I’m just going to drive into the office. I live two minutes away. I’m going to drive in. Well as I’m about to drive in, the phone rings again or the pager goes off, I get a second consult. And this one was for across town, across the bridge. He said, uh-oh, now that’s the defining moment. I have two stroke alerts. Usually never happens. You get about one every two hours and I have two in a minute, so I’m going to have to use telehealth. So he gets on and all of a sudden a third page and then a fourth page while he was on. So within a 15-minute span, he had four pages for three different hospitals, different patients, all this stuff.

I said, well, what happened? He said, no big deal. I saved four people and triaged appropriately and saved them all. I said, well, what would you have done last week if we didn’t have this system? And he said, well, I would’ve triaged and picked the younger patient or the most important – whatever I would’ve based on protocols – and I would’ve seen one out of the four, and the other three would’ve had months of rehab or maybe not made it or whatever it was. And so at that point, he was bought in and it became, we transitioned it from, okay, we’re going to somewhat use it to, no, this is the way you have to do care because the old way is no longer safe. We can no longer wait 45 minutes to see the doc. We need to see him in three minutes. Sure. We quickly transitioned over and then it became the next, goodness, five years let’s say, until COVID, of expanding that, taking that vision out to the organization and the community, and saying, this is beneficial. This is a game-changer for us to deliver care not only for the physicians. Yes, it’s convenient for the system, it’s more financially feasible.

And for the patients, again, back in the day, reluctant – why do I have to see a guy on a TV? Well, okay, the alternative is you wait 45 minutes while your brain is incapacitated. Alright, fine. I’ll see somebody now. And so it was a little bit of evangelism. It was a little bit of goodwill and talking about benefits and selling the concept and then COVID happened.

Brandofino:

Yeah, that’s interesting because obviously telestroke has been around a long time and it’s interesting to hear the stories about how it got started and then you kind of think to yourself, wow, how did we ever operate without it? Right. You mentioned COVID. Was that the watershed moment for you guys at Lee where it obviously sounds like stroke became a critical app earlier, but where virtual care in general, this whole idea of hybrid care, was that the watershed moment for you and the executive team at Lee?

Witenko:

Yeah, absolutely. I remember actually December of 2019 it was, I presented to our senior leaders, our board of directors – here’s what we’re doing with telehealth and here’s the vision, here’s the plan. And it was met with a little reluctance of it’s great and all it has specific niche use cases, behavioral health, neurology, hard-to-reach, niche environments, genetics, et cetera. But for the bulk of it, internal medicine, no, we can see the patient all day long. And really the challenge was we weren’t getting paid. Unfortunately, we’re a mission-based organization, but at the end of the day, no margin, no mission. How do you financially feed the beast without reimbursement? It’s beneficial, saving lives, all this stuff, but if you don’t get paid from insurance… And so I think we were always waiting, we’re in a non-parity state in the state of Florida, and so we’re waiting and watching. Goodness, 30 of our fellow states in the nation had passed this, but Florida hadn’t. So we’re stuck and struggling. And then the senior leaders are like, it’s great, but just continue to kind of grow and grow and grow and we’re not going to expend a lot of time, energy, resources into this.

And then March of 2020, so four months later, three months later, we were looking going, okay, this is where we want to go and this is a slow and steady progression, and then suddenly we shut our doors just like everybody else. And I remember getting on a call, I was on spring break with my family and I get a call from the senior leaders and they’re like, Hey, that telehealth thing you were talking about, we need it now. Okay, well it’s going to take, and they said, and we need it by Friday. I was like, well, today’s Wednesday. What do you mean by Friday? And they said, well, we’re shutting down everything. We’re going a hundred percent virtual. Well, our system can handle five at a time, and we needed to flip that over to 500 at a time or a thousand at a time.

So that became the moment of, wow, this is how we’re going to not just improve business, but this is how we’re going to sustain as a company. We either shut our doors and safely distance from patients, or we pivot. And so it became we need to pivot now.

Brandofino:

And I remember going through that with you guys and it was a crazy time with you and obviously a lot of other customers. And so that was definitely I think a watershed moment for the healthcare industry to figure out how we can continue to operate and give care during the global pandemic. But then coming out of that, it’s kind of interesting to me that during that time, I think most of the focus and even the media’s attention was on that physician/patient – I can’t see them in person, so I’m going to schedule a remote telehealth session with them and give them a prescription – that outpatient model was most focused on. But the interesting thing coming out of COVID, what we’ve seen and we’ve seen it with you guys as well, is expanding programs on the inpatient side and how this hybrid model has really started to take off. And I’m wondering if at some point it’s table stakes to be able to see and hear in every room. And so maybe you can talk a little bit about the expanding programs now on the inpatient side and what your thoughts are around – do we take the word “tele” out of healthcare now and is it just how we deliver healthcare?

Witenko:

I love that line. Yeah, it’s interesting. Again, it’s hard being an evangelist, a prophet in your own land, if you will. And as we’ve been beating the drum, and I remember sitting probably, I don’t know, April, May of 2020, my parents called me up and they’re like, we’re seeing our doctor over telehealth. Do you know anything about this? And I was like, this is what I’ve been doing for the last five years. And they finally understood it. And I think a lot of folks are still of that mindset. It’s taken a while. I mean, I sat in a meeting this week as we’re talking about, we will shift to inpatient in a second, but for ambulatory, how do we move from, sure, we have some docs doing it, but we’re not a high percent. Three, four percent of our visits from an ambulatory perspective are telehealth and we’re pieces and parcels.

But we have newer physicians coming in out of residency saying, okay, what day is my telehealth day? And that’s not a like, Hey, I’d really love to do this, that’s a demand coming in of which day. Okay, great, I’m in the clinic four days, which day am I at home? And it’s no longer a bargaining tactic, it’s really, this is my demand coming in. And we’re trying to figure that out. So again, we’re a little slow strategically, how do we move to a virtual-first model? The effecient ones aren’t, okay, I’ll do telehealth one out of every 17 visits. That doesn’t work. It needs to be batched. So we had a physician call out the other day and they said, Hey, I’m sick. I can’t get kid care or whatever. I’m switching to virtual today. And our system’s broken and it was like, no, we need three weeks a month to schedule you out. And it’s like, so some of the tools are still slow to adopt. How do we change that visit type, immediately switch the whole thing. And we’re still of the mindset of, well, come into the office. This is what we’ve done for, like Henry Ford, this is how the factory runs. We’ve done this for a hundred years. And shifting that thinking is a little tough. It requires a little more thought of what’s more efficient.

And then moving to the inpatient model, it’s the same kind of thing. We’ve done nursing forever. We know nurses at the bedside. It works all day long, this is what they do. And suddenly we’re starting this virtual nursing program and we’re met with some cultural reluctance of is this really going to work? Are we going to, it’s an extra cost. Well, it is if you’re thinking short term, if you’re thinking shortsighted, yes, we have to put another person in the room, we have to staff this. So there is an extra layer of cost to it. But then you start looking at the efficiencies. I was looking last night, our time to discharge, M7, length of stay, readmissions, education, patient satisfaction, everything is through the roof.

Brandofino:

Nice.

Witenko:

So it’s a little bit different of that ROI model of how you can’t just look at, yes, it’s an extra cost, but it’s really the big picture of what is the cost to deliver care, and then when does this become part of the standard? As you said, it’s no longer the virtual care, it’s part of your care team. It’s part of the expectation. I come in the hospital, I want that. We’re calling it internally the operation warm hug of I want to know that you’re there for me when I need it, and I want to know that you’re there for me when I don’t know I need it.

Brandofino:

Right, right. Yeah. It’s got to be part of the healthcare process because you never know when you’re going to need it. Right. So you were there at the beginning, you made it through COVID. We all kind of weathered the storm and we’re seeing growth in Lee’s expanding programs. What has changed in that time from an executive involvement and oversight on these programs and the exposure? It would seem like it’s now reached the top levels and it’s no longer just you and Dr. Carracino going off and doing some things. So what has changed as this has become more critical?

Witenko:

Yeah, I think COVID revealed a lot of stuff. One, it changed the consumer expectations and perceptions of, Hey, I want that personalization. I want care the way I want it. So we’ve had to rethink a lot of stuff in terms of simplest notifications. Do you want to be called, do you want to be texted? Do you want a hot air balloon? We’re dealing with a patient right now who said, I don’t want you to call. Okay, well, so we’re having to trigger those individual notifications, and it’s the same as, why do I have to be seen in person? I’m going to come in for my follow-up to read an X-ray that I already have the results immediately through my patient portal. You’re going to make me come in? Again, some of it is stuck in the old way. So what I’m enjoying now is the conversation has shifted from reactionary to how do we really want to deliver care and what do our patients want, what do we want?

It can’t just be great for the patients. That may not work for us. And it can’t just be great for the docs. It can’t just be great for the system. It has to be a mutually beneficial relationship of saying, you know what? One out of every – let’s say you come into the PCP twice a year above 65 kind of wellness – so one of those is in person, one of those is virtual and pushing that. So maybe some patients can’t. I get health equity and we’ve got to make sure everybody’s on the same page, but we need to figure out that better model. And those are the conversations we’re getting to have now, wrestling through not from a reactionary of, Hey, let’s just put it in, we’ll figure it out later and let the chips fall as they may – now it becomes the pragmatic question of we’re struggling with resources, reimbursement is getting cut constantly. We just went through cat five hurricane, so that’s a whole separate issue. So now how do we think smarter? And we brought in new leaders, we’re looking at the system saying, what is our strategic course of events? How do we compete in the competitive landscape? And so it really becomes that proactive, let’s make intentional, targeted, rational decisions about the future of care delivery. And those are the fun. I mean, it is painful, it’s exhausting, it’s deep, it’s heavy. But those are the good conversations rather than lemme just put out another fire.

Brandofino:

The competitive nature of health systems is something that I learned as I got involved in healthcare when we launched Caregility and it was a surprise to me, and I think it was actually you that said to me or maybe Dr. Carracino, we want to own the experience throughout the continuum of healthcare for our patients. And that’s why it was so important for you guys when you expanded the outpatient to continue that experience and give that to patients throughout. And so it’s just great to see you guys driving that vision. And it is a competitive thing. If you can capture those patients and give them a quality experience, they’re going to stay with you throughout their healthcare continuum.

Witenko:

And again, you really have one shot to win the patient, to lose the patient. Really gone are the days where, okay, I’m going to experience quality care. We can stand on that quality. Well, everybody should be doing quality. There’s enough data out there and metrics that you’re getting a quality experience. Now it becomes how efficient are they, how optimal are they? Are we getting you out sooner? As beautiful as our hospitals are, nobody wants to sit there. I’d rather spend a week on a cruise than a week in our hospital, better food, prettier view, all that kind of goodness. And with insurance, probably it’s a lot cheaper to be on the cruise. So how can you get me out sooner and while I’m there make it as enjoyable as experience?

So as I’m sitting there watching the virtual nurses, they’re connecting with their patients. The normal bedside nurse is so busy, we’ve layered so many things on those poor nurses and they run in the room, they do their task and they’re out. Well, the virtual nurse has not flex time, but the ability to come in the room. They’re not there for that quick or they’re doing multiple, they’re able to multitask. They’re not transactional. They come in and they’re starting to be relational. And this is where you run into the culture rub of why do they know my virtual nurse? The virtual nurse isn’t the one that cared for them. I’m the one that put the bed pan there, They should love me. And all these survey scores are coming back saying, I love my virtual nurse. And so again, it’s creating that friction point. We as a system, but overall the benefit for the patient, the patients love it. You’re getting that individualized attention, that care, that connection that you’re getting me out sooner. You’re getting me seen, you’re bringing in my wife to a conversation, the translator, the education, all those components right there at their fingertips. And that’s what rather than, all right, I’ll sit in the room and listen to watch The Price Is Right on reruns again, they really want that. Give me an experience. I can get it home. And then that becomes, that’s what we’re working on now. That hospital at home is really that end goal. I don’t want to sit in your hospital. I don’t want to acquire something else while I’m there or get more sick. Can I do the same safe treatment at home? And what does that look like? And logistics and food and DME and all that kind of stuff. But it’s doable. There’s programs out there that are running a hospital at home. It’s how we delivered care a hundred years ago. So that paradigm’s going to shift, I think massively heavy in the next probably 20 years.

Brandofino:

So Jon, fast forward three years, what do you vision? What’s your vision for Lee? I know we’ve talked about a lot of different things, but what would you like to see or where would you like to see Lee be in three to five years?

Witenko:

So I saw something recently, and I don’t know if it was Mayo or Cleveland Clinic. I kind of give them credit of it: The room is aware of me. And so it’s not, the room becomes part of the care team and suddenly now you start layering AI on top of that and the room is cognizantly aware and contributing to the care team. So it’s saying, Hey, this patient is sleeping. Whatever state they’re in, their patient is sleeping, they’re agitated, their voice as we’re rolling out voice detection kind of stuff from a security aspect. But what if it’s the same in the room? Hey, this patient is depressed, the patient hasn’t seen anybody. There’s been no visitors for a day. Let’s send our therapy dogs in there or whatever. So having that awareness of the room, of the state of the patient, or do we need to, is the patient in distress physically? We can start looking at the vitals in the room? Can we start to record just the temperature of the room or then the patient’s gone, okay, can we make sure the room’s turned over for the next patient? Those type of things – we become more efficient as a system. We become more reactionary to the patient and start to anticipate their needs.

We’ve done the same thing with predictive modeling, with risk of readmission, sepsis, deterioration index. We start looking at data points and we’re looking at those data points based on vitals, based on clinical data. Can we start to incorporate those – the epigenetics term or I can’t think of it – off the epi-vitals of what is the next closest? And don’t just tell me my heart rate, but what about the other stuff that’s going on? And again, that room becomes part of the care team. So the easy ones, yes, we’ve got to put a device in the room to start to aggregate that data. We’ve got to have a way to connect to the patient. The patient has the way to connect to us. And outside of that, and really we’ve built so many different applications and pieces now you start to integrate all those and that’s where the magic happens.

Brandofino:

Yeah, I love that. And that’s our thought as well. I’ve been using the term responsible AI because just having technology doesn’t mean anything, but in how you describe it, if you think of the room as having multiple sensors in it that we could gather information from and then provide that information to the right people at the right time, augments care. And that’s the key. So it’s great to hear what your vision is and obviously we’re looking forward to trying to be a part of that.

So you guys are a little ahead of some customers. You may be a little behind some of the big guys like Mayo in some things, but what advice would you give to some of those health systems that maybe have only done outpatient and they really haven’t crossed the line into inpatient or really making virtual care part of their just healthcare strategy? You have a couple of pieces of advice for folks that are in that stage?

Witenko:

Yeah, and the advice probably hasn’t changed since COVUD. I was fielding calls – again, we’ve been doing it for a while, so we’re a step ahead of the others. And so I remember throughout COVID people calling and going, what do I do? And referenced Apollo Levin where they’re sitting in the room and Gene Hackman walks in the room, dumps the box and says, this is what they have on the ship. How do we make it work? There’s a roll of duct tape, a cheeseburger, and a hammer. And they’re like, okay. And so it’s really, the guidance is start somewhere. It’s find those physician champions, the nursing champions, the advocates that’ll experiment and learn through the process. So for us, again, we started with neurology. Should we have started there? Maybe, I don’t know. We started somewhere.

Then suddenly genetics called me. I didn’t even know we had a genetics team, and they called and saw the vision and said, could we connect to babies? Then our pediatric neurology said, I’ve got patients driving two hours because we’re the only pediatric neurologist in the Quad County area. It was just, you start somewhere and then you figure it out and go, well, this was good. This wasn’t, okay, let’s pivot a little here. It doesn’t have to be this massive big bang. We’re trying to put devices in every room. We started in a couple rooms and we started on a pilot unit. Same thing with virtual nursing. We started on a pilot unit. We learned quickly, we had these visions that, yes, it’s going to go this way, this way, this way. Okay, maybe that wasn’t right.

So dream state, yes, I’ve got a virtual command center, a hundred thousand square feet with 500 people in there, all monitoring SpaceX. The reality is I’ve got three people in a broom closet and it’s working. And so then it’s those small wins, the flywheel concept that you just continue to build and build on those. And then suddenly we hit critical mass where I’ve got 17 broom closets and I put in a strategic capital request to say, this is what I’m going for – I can consolidate my 17 broom closets and 38 people sitting in nine different locations, and now I’ll gain even more efficiencies. So that’s where the wins start to compile and win games.

Brandofino:

Well, I appreciate you joining and sharing your story with us, Jon. And you do participate in our SIGs. So if there’s folks that are listening to this and want to talk to Jon, please come join our SIGs and I’m sure he’d be willing to share with you. Thank you very much. Appreciate you joining.

Witenko:

No problem. Hopefully I’ll see you soon.

Brandofino:

Sounds good. Thanks a lot.

Witenko:

Appreciate the opportunity, Mike.