How Can We Make Telehealth More Equitable?

[00:00:00] Jared: Hello everyone, and welcome back to another enlightening episode of the med+Design Podcast where we delve into the inspiring stories of healthcare innovators. Today we're truly honored to host Dr. David McSwain, a leading figure in digital health. Dr. McSwain has become a pivotal force in revolutionizing healthcare through the integration of advanced digital tools and telemedicine initiatives.

From his earlier days as a pediatric critical care physician to his emergence as an influential leader in Health IT. Dr. McSwain embodies the dynamic evolution of our healthcare system. He stands with the crossroads of medical practice and digital transformation, ushering in a new era of value-based patient-centric care.

His groundbreaking work with the Sprout National Telehealth Research Collaborative demonstrates a true commitment to reshaping the healthcare industry. His insights shaped by years of hands-on experience and an unwavering dedication to improving patient outcomes make him exceptional guest for our podcast.

We're here to explore his journey, delve into his transformative initiatives, and discuss his thoughts on the future of healthcare. So without further ado, let's kick start our fascinating conversation with Dr. David McSwain. Welcome.

[00:01:05] David: Hi. I'm excited to be here and I gotta say I listened to you guys podcast and you always do such fantastic introductions.

Sets the bar really high for the conversation.

[00:01:15] Jared: Thank you. And just like getting right into it then, with your expertise in telemedicine and telehealth they're often seen as, revolutionizing, patient care. And so for those that are less familiar with that world, what really is telemedicine and then also on the other side, telehealth.

[00:01:32] David: Yeah. So telemedicine and telehealth it's not one thing. And that's a actually a really key point. There are so many different technologies and many different approaches that fall under the umbrella term of telemedicine and telehealth. Telemedicine generally is considered the provision of care across distance using technology.

Telehealth is a broader term that includes other disciplines. It includes any sort of activity that enhances the health and wellbeing of patients and contributes to their overall experience with the healthcare system utilizing technology over distance. But people often when they hear the word telemedicine, they think real time audio video visit with your doctor, and that's the thing that most folks are familiar with. But telehealth and telemedicine encompasses remote patient monitoring. It encompasses asynchronous interactions, tele icu you know, there's so many different types of ways that this technology can be deployed that it really empowers clinicians and empowers folks in the healthcare field to change the way that we practice medicine.

[00:02:49] Jared: Fascinating. Throughout your career, what would you say have been some of those significant advances that you've seen in the field. And then with that as well, something that I was thinking about was the recent pandemic and, it seems that telemedicine and telehealth, those terms started to come up quite a bit more for the everyday average joe, and I'm sure there's been a lot of significant advances even prior to the pandemic.

Did the pandemic also set some fire to some of the stuff that maybe was already on its way out as well?

[00:03:19] David: Yeah, the pandemic had a bit of an influence on telehealth to put it lightly. The biggest change in the field and most beneficial change in the field that I've seen since I've been engaged in this for the past 13 plus years is the evolution from a standalone type of service to a more integrated approach to integrating virtual care and telehealth into the day-to-day practice of healthcare across multiple disciplines and often integrating multiple disciplines, multiple specialties, and even multiple technologies into the various encounters that you can support using telehealth.

And that's really critical because if the services provided via Telehealth are standalone services, they can actually lead to increased fragmentation of healthcare, increased costs, and less coordination. The more that you can integrate telehealth services into the day-to-day practice of healthcare by the folks who are actually providing the services in person as well.

The more that it can improve efficiency, improve coordination, improve outcomes, and the more that it puts it into focus for hospital administrators, for policymakers, as an integral part of how we move our healthcare system forward. What the pandemic did is it forced that integration. And there's no doubt about that.

That shift from being more of a standalone service to being a more highly integrated service occurred over a period of weeks, and that's something that probably would've taken five to 10 years otherwise. Because due to the pandemic and the restrictions that healthcare systems faced, the concerns over

contact and isolation that healthcare systems were facing in order to protect their staff and their physicians and their care team members and their patients and families. It really forced them to very quickly pivot towards integrating this into their usual approach. And fortunately, while the overall utilization of telehealth has certainly fallen back down, not all the way to where it was before, but certainly to a lower level. That integration and that focus on integration has remained, and that's a wonderful outcome of everything that we've gone through with this.

[00:05:56] Jared: And with that, what were some of the technologies that you say have stuck around versus, some of the stuff that maybe has dialed back a little bit as well?

[00:06:05] David: Yeah. I think the key technology or approach to technology that has emerged as a result of the pandemic, or has been accelerated due to the pandemic is integration of virtual care technologies and applications into the electronic health record. In many cases, prior to the pandemic, these were separate platforms.

Often you had the encounter summary being imported into the media tab via Pdf if it was imported at all, if the established providers or the established healthcare institution even had any visibility into those visits, it was generally, in a somewhat inaccessible way that didn't really fit in with their workflows and didn't contribute positively to that coordination of care.

What you saw with the pandemic was a rapid pivot of the EHR companies themselves to put a huge focus on integrating telehealth and virtual care into their platforms to streamline that and make it easier for clinicians. And everyone across the healthcare system, patients and families to access care remotely.

And that was a huge factor in that integration as we moved through the pandemic and subsequently.

[00:07:25] Jared: Let's go back into what actually in your career got you into telemedicine in the first place? Like how early on in your career were you into it? Where were you at that point when you realized like the potential that it has on the healthcare industry?

[00:07:36] David: It happened rather suddenly once I got into pediatric critical care practice. Because one of the major challenges that I experienced early on as a faculty physician in pediatric critical care was that we would get these calls from remote, rural, smaller community hospitals where critically ill children would come into those emergency departments and

while the staff at these hospitals are incredibly dedicated and incredibly talented people, they may not have the resources, the expertise, or the experience to handle those sorts of really critical situations. They may also only see at a small community hospital, one or two critically ill children come into the emergency department every month, and I was getting these phone calls that were extremely, that could be extremely stressful for everyone involved because trying to gather information and assess the situation over the phone when the person who's on the phone with you is also trying to manage the situation and care for the patient, talk to the family, all of those things can be extremely difficult for everyone.

One of the approaches that we took to addressing that was putting this real time, high quality, high definition audiovisual communication in place via these telemedicine carts. That allowed us to very quickly connect into these remote emergency departments and be virtually there in the room with them.

At the bedside helping to care for the patient, not just pulling the providers away from the bedside to ask a bunch of questions. And there were instances where I was able to help guide resuscitations. I was able to get our PICU nurses engaged on my end and provide guidance on the administration of medications.

It was really incredible, the difference that it made in understanding the situation, what was going on, and making better recommendations and in making better decisions with regards to what to do with the patient, whether they need to be transferred and to where they needed to be transferred.

We actually cut down significantly on the percentage of patients that we admitted to the PICU when you compared the telemedicine consultations with telephone consultations, and this is, it's not entirely because we made interventions that improved their clinical status and made them better to allow them to go to the floor.

Often it was because we had a much clearer picture of exactly how sick they were, how much support they needed, and in many cases could say, yeah, this patient actually is doing okay. I agree, they need to be transferred because we have the resources in case they do deteriorate, but they can go to our floor.

So they'll be here on site and we'll be able to care for them, but they don't have to take that PICU bed. And they don't have to come through the PICU and have all the stress and and things that are associated with that for the family. So it made a huge difference and it really drove home the kind of impact that you could have with this technology and its impact not only to the patients and to the families, but to those rural community hospitals who became huge fans of this technology. The degree to which it decreased the burden and the stress associated with one of these children coming into their emergency department was really remarkable, and we got that feedback very often.

It just reminds me of one of my best friends who lives in a rural part of the country in East Texas, I guess almost Arkansas. And like they just got annihilated by the storms that were just passing through there, the heat wave and stuff. And he was talking about how like, The hospital is too far away, for people that are going through like heat exhaustion and whatnot, and like a lot of people don't even know what to do right now.

[00:11:48] Jared: Of course the power has to be on, to be able to utilize some of this technology as well.

[00:11:52] David: Yeah, I grew up in a very rural part of North Carolina and being, remote from high levels of care was pretty much just an accepted part of life. Fortunately, I didn't have personal issues with significant health issues. My family was healthy. We didn't experience some of the hardship that a lot of people in rural communities face. But it certainly gave me that awareness of what some of those challenges were.

[00:12:19] Ty: Yeah, you spoke to earlier about the, I guess the fragmentation that can happen as a result of telemedicine and the story you just shared about the incredible connection that's enabling, that point of care where you need have higher specialties.

Can you also speak to, I mean like physician wellness of course is a big topic lately. About just the individual physician who now that you have compelling clear access to all these areas of need, how does the physician themselves, who is being called upon now for maybe a broader access point, be able to manage their time from a wellbeing standpoint?

[00:12:54] David: Yeah. I think that this applies across all kinds of Health IT, and it's that the reduction of burden for our care team members and our clinicians has to be a central focus of what we're doing. And I think one of the challenges that you've seen with certain technologies the electronic health record, certainly in the first decade or so, is a great example.

Is that because they were developed without that focus on the clinician and workflows and integration and making it easier we've seen a substantial increase in burden in a lot of areas. I think our pediatric critical care telemedicine program is a great example of having that focus on ease of use, streamlining the care, because the last thing that a emergency room physician wants to have added on top of a critically ill child coming into the emergency department is trying to figure out how to log into this new system, oh geez. That they're not that familiar with and operate the buttons and know how they're supposed to use this thing.

And so the biggest takeaway from that experience was that the only way this was gonna be successful, was to have a huge focus on workflows and the staff experience on both sides. We had the same kind of thing going on with our PICU providers who were providing the consultation because they're dealing with on their end, 15 critically ill children in their unit.

Now a phone call might be a little quicker. But you had to demonstrate to them, the value they could get from that video connection was not only very easy to do and quick to do, but it would greatly enhance the information they're able to obtain, make their work easier, make their decisions easier.

And that was the biggest key. And I think when you look at implementing technology and especially the adoption of technology. If you don't have the provider experience and the patient experience as a major factor from the very beginning, it's likely going to fail. Especially the more intense the situation, the easier it has to be to use the technology in that moment.

That's incredibly critical and it's something we always focused on.

[00:15:33] Ty: That's one of the things we talk about is, and we use the adoption of electronic health records as an example of top-down

technology, push that

you know when you make a mandate like that, you do it at the expense of what the experience is for the end user on the backside versus going from a market pull

standpoint where you go through and you try to deeply understand empathetically what's happening for the clinicians, the patients, and try to make sure you understand what that experience is and have the solutions.

There's an array of solutions where like you're thinking comprehensively about each of those solutions

[00:16:10] David: and not just tied to one technology. Anyway, absolutely agree with that approach that

you've outlined there. Yeah. One of the big challenges with the electronic health record, was that the that things that it facilitated most effectively early on were around billing and coding and compliance.

So it made people on that end, it made their lives much easier. But then because that was the simplest, easiest thing to really optimize early on. Actually added to the burden for the clinicians. And it is more complex to streamline clinical workflows, but we have to put that kind of effort in.

[00:16:47] Jared: You mentioned ease of use as one of the potential barriers for people to use these technologies and we're talking about five to 10 years out, prior to the pandemic. But what were some of those barriers that you were experiencing to the integration of the technologies that you were really excited about at that time for telemedicine and for telehealth?

Obviously two different fields.

[00:17:07] David: Most of the barriers really did relate to that user experience more than anything else. I think, we were fortunate. In the fact that we were working on pediatric critical care programs, because if you go out to a rural emergency department and say, Hey, would you be interested in having subspecialty trained pediatric critical care support when kids come into your emergency department with, critical illness or injury?

The answer is never no. So getting buy-in to the concept was not a problem. Now that's not the case for every telehealth approach, and it's certainly not the case for every health IT approach, but in our case, we did not have an issue with having folks be interested and understand the value that they could get. What the challenges were was getting that not only designing the technology in a way that would work on both ends to be as seamless as possible, but getting over some of the hurdles of the other stakeholders involved, who would say no, they really do. The ED providers really do need to log in first and enter some patient information so that we've got that record and we can pull, have that available before they connect that consult. And I said if you want 'em to never use it, then yeah, that would be something we could do.

But we made it so that literally I knew where the carts were in each of these hospitals. And I knew that one of the great things about this technology is I knew the people in those hospitals, it was, somebody would pick up and say, Hey, Carl can you, and or if it was someone who wasn't familiar with the technology, which if you think about it, is many cases, if you have an ER where two to three pediatric critical care pediatric patients come in per month, then any given staff member, it may not see a really critically ill pediatric patient for a year or more. So it doesn't matter if you've trained them on the technology before. Know if it's been a year since they did it, they're not gonna necessarily remember that and they may be new staff and there's all kinds of reasons.

So what I ended up doing and what many of, and what my colleagues ended up doing is we would guide them even if they had no idea what we were talking about when we said, let's use the pediatric telemedicine cart. I would say, listen, it's located outside of Carl's office. All you gotta do is go grab it and roll it to the bedside.

That is it. And I would call in and I would pop up there on screen. Sometimes I would pop up on screen, before they got to the cart and wave and say hi. And then they just roll you into the bed and that is it. And that was the biggest key by far, to making that a successful program.

And there must have been a lot of design that went into making that possible. It was huge because the existing telehealth programs prior to that, for things like telestroke, for example, great program, huge benefits, but it's very cookbook, right? It's very much. Follow these steps, enter this information, get this CT scan, get it loaded.

And once that's done, we will get our neurologist on board and they will run you through this examination. So the platforms for an ED based telehealth solution were designed around that. And the initial push for our program was use the same platform, use the same approach, but it was very clear as we were discussing how to do this, it simply doesn't work in a pediatric critical care situation because the situations are far more varied. The assessment is always different. The criticality of making that audio visual connection is incredibly important. And as I said, it's less frequent. These eds may get three or four stroke patients a day.

So they're very used to getting in there, entering that information, completing that form, getting it, that visit kicked off. You can't do that for the critical care sort of evaluations.

[00:21:30] Jared: And speaking of, initiatives that you've also been involved with maybe you could tell us more about SPROUT, the National Research Collaborative.

Yeah. How did this initiative come out? What's the mission? How's it been going for you so far? Being involved in that?

[00:21:44] David: Yeah. My focus in all the technology work that I've done has always been on having it be evidence driven. And that is sometimes a challenge in the health IT space because it moves very quickly.

The people that are really deeply involved in the health IT space may not be very familiar with research. With the processes you have to go through there. Also, a lot of those research processes and tools are not designed to facilitate research on technology. I would say, I was giving a presentation at the American Academy Pediatrics National Conference back in 2015 talking about those challenges of conducting research in the telehealth space, but the critical need to conduct research to be able to drive adoption forward, to be able to drive high quality programs forward in an evidence-based fashion, because that's what we do in healthcare, right? We make clinical practice changes based on evidence. Also, because the volume of a lot of pediatric telehealth services was fairly low.

We really needed to have multi-center pediatric trials, but since even two programs that ostensibly have similar goals may be designed very differently. And so there's a lot of challenges of how do you pull together a multi-centered effort? So at that presentation there were four people that came up to me afterwards and said, this sounds, we would love to work with you on establishing something like that.

And so that's how SPROUT got founded and it stands for supporting pediatric research on outcomes and utilization of telehealth. I think for the first two years of the organization coming up with that acronym was my greatest contribution. Our approach is not necessarily to conduct the research ourselves. We're not looking to get our names on everything. What we're looking to do is there is to support others across the country to conduct research on their programs and to connect people across the country so that they can develop these multi-centered research studies.

And then we develop the tools and the frameworks and provide education around how to conduct these studies to promote integrated, equitable, high quality telehealth services. And while it was started by a group of pediatricians we have always designed our tools and our approaches and our education with an eye towards the broader telehealth community.

So we are expanding now into the adult space. Working with a lot of adult focused organizations. The American Heart Association is one a society called Search which is a great research focused telehealth society that puts on an annual conference every year called the National Telehealth Research Symposium.

Everyone should look that up and and register. It's November 7th through 9th and we've been able to get participation from hundreds of institutions across the country. We've been able to support, so many high value research efforts and provide mentorship to so many folks that are aspiring in this space.

It's been a very valuable project and something that was certainly incredibly valuable during the pandemic.

[00:25:19] Jared: It must be incredibly fulfilling to have that full circle moment of, you've been working in this space for so long and now you're able to facilitate other people and their dreams and trying to help advance it forward.

And so what are some of those initiatives that you're really excited about right now that you can talk about? I'm sure some of it you can't really talk about, but maybe some of the stuff that's already been out already.

[00:25:38] David: There's a number of things. Obviously some of it's in the telehealth space and some of it is beyond.

Since I'm the System CMIO for UNC Health, I certainly have moved into a broader technological focus. From SPROUT standpoint, we are really focusing on the value and equity aspect of telehealth and really getting into some of the policy considerations, payment considerations, and developing multi-stakeholder collaborations to direct the evidence generation towards informing policy

around payment so that we can support that provision of integrated virtual care services. The other thing that you've seen that certainly emerged during the pandemic is that telehealth, while it scaled rapidly, didn't scale equally for everyone across the country and some disadvantaged populations in particular non-English speaking populations, for example, but also folks in rural areas that may not have as strong internet access.

Folks that work in jobs that don't allow them to step away to participate in a video visit. They had a very different experience with that scaling of telehealth during the pandemic. And there are specific features and characteristics of telehealth programs that we can identify that are associated with more integrated care.

Equitable care, higher value care. And so we're looking at really driving the adoption and driving policies that promote the adoption of those integrated equitable high value services. The other area outside of the telehealth space, that we're working on at UNC is in artificial intelligence and we've done a great deal.

We've put a great deal of effort and really established ourselves as leaders in that space particularly in the realm of applying artificial intelligence to support reduction of burnout and burden for our care team members. There's a lot of activities going on there, a lot of excitement. I think you look at.

One of the big sources of burden and burnout is information overload and excessive repetitive tasks. And the way that artificial intelligence functions optimally is in offloading some of those repetitive tasks as well as taking massive amounts of information and presenting it in an actionable, concise way.

At the point of care, at the point that it's needed the most. And we have huge opportunities in that space, particularly in the population health arena. Because there's a, if you think about the amount of underutilized information that's available in an electronic health record, from studies that have been previously done, lab results, visits.

That could be applied to identify patients at risk for different conditions that could be pulled from the record to help provide better coordination of services without even having to order any additional studies, without the cost associated with that. The potential impact, especially in a value-based approach, is just immense.

So we are really focusing in on that the reduction of clinician burnout and the optimization of value using that data.

[00:29:12] Ty: Could you speak I'm glad you brought up ai, but to like specific tools or tactics that are within that, I mean like large language models have been a huge hit lately with open ai, but I'd imagine what you're describing some of that seems to fit some of those capabilities, but others not so much

[00:29:29] David: yeah, I think large language models are extremely promising in this space. And UNC Health is one of only four institutions around the country who have been chosen by Epic to pilot one of their large language model GPT interface to facilitate responses to patient messages within Epic.

This is not the ai, creating and sending the message. This is the AI drafting a message based on information from within the record that our clinicians can then review, edit, discard if they want, start over or send, and that holds immense potential for offloading the burden of that in-basket message volume.

I think where there's a huge amount of potential as well using large language models is chart summarization. Because the volume of data and information that can accompany a patient, to a new patient encounter or to even going back to a physician they haven't seen in a year.

They may have had two ed visits, a hospitalization, five specialist visits, who knows what, particularly for chronic and complex patients, that it can be extremely daunting to review all that information and you, and difficult to feel like you've done it fully and effectively, and these large language models can be trained to pull that relevant information for the clinician, present it to them in a usable way, and then be incorporated into their documentation, be incorporated into their care management plans.

I think the potential there is just huge. So we're really excited about that work.

[00:31:16] Jared: And when you're talking about also just the time save in general. We had a past participant come on and say that the eight hours a day that you would think a physician works is really she essentially said there's estimate that it's a 26 hour day, which obviously impossible, but I think the gist of it is saying that it's impossible to keep up with the amount of work that a physician kind of has.

She's talking about private practice in particular. And with integration of the sort of technology, how much of the workload that sort of extra outside of patient care alone gets whittled down. I can imagine at least some level of a multitude.

[00:31:50] David: Oh yeah.

And this, one of the challenges of value-based care is that it often requires adherence to certain metrics of quality that require documentation within the ehr and addressing certain things with the patient if they have a chronic illness, if they have hypertension, diabetes, et cetera.

And the information that your previous guest was referencing is a study that showed that in order for a primary care physician to actually complete all of the preventative guidance and and complete all of the metrics that are required to meet all of the requirements for various value-based contracts and whatnot, it would take them 26 hours a day.

And that is obviously not possible. But again, this is where aI has the potential to just vastly improve our provider experience because a lot of that relates to simply being able to pull the right information from the chart and present it to, and present it in a way that's really usable and efficient and effective.

Some of that outreach can, some of the interaction could be done in an automated fashion, if it's an established patient with an established diagnosis and they just need to get this particular lab test done, they need to get a hemoglobin A1C done because they're diabetic. That doesn't necessarily have to be something that the physician remembers to mention or remembers to do when they have their visit.

I think there's huge potential there to make those to make those adherence to those requirements and to make the overall experience for our physicians far more efficient. And that's really where technology aligns so well with value-based care because, Value-based care is really focused on improved efficiency, reducing costs, improving both short and long-term outcomes reducing the burden of chronic disease, et cetera, et cetera.

And so much of what we do in the health IT space has that same focus. And if you're in a fee for service environment and one of the big benefits of your technology, is cost reduction. Then who are you saving money for? You may actually be losing your health system money if you do that, right? Which means that the incentives aren't aligned and regardless of, your health system having a desire to benefit their patients, which of course they do, if you're talking about yeah, we can do this, we can do this thing or this thing. This thing is gonna make us money and improve the care of our patients.

This thing is gonna lose us money and improve the care of our patients. Which one are they gonna do? So the way that value-based care and technology aligns is that it aligns those incentives towards that efficiency. Cost reduction of chronic disease burden, improvement of long-term outcomes.

That's why moving into more of a value-based care model is so critical to advancing technology to achieve the full potential of what it can be in healthcare.

[00:34:55] Ty: Could you take a moment to speak to the entrepreneurs, the healthcare entrepreneurs that are out there, that are trying to make sense of how they can set up their new venture from a value-based care context, because, It seems like the difference in incentives and risk models and everything is a little bit different, but maybe just for those like entrepreneurs who are like trying to figure out how to exist in a

value based care environment.

I don't know if you've seen successful examples of that.

[00:35:22] David: Yeah, the key is to focus on the whole patient to focus on the whole system. And that requires an understanding of breadth of stakeholders, including an understanding of the payers and understanding of the viewpoint of, hospital administration, of clinicians, patients, and families.

And that's can be difficult, certainly. But I think the thing that I've seen with a number of startups is a little bit more of a singular focus on we can improve convenience for patients, but if you don't consider the impact on providers or how exactly it fits into a provider's workflow, guess what?

You're gonna have a bunch of patients that are participating with your product, and no providers to actually act on the information that they're providing. I think that if you can put that focus on improving value for the system and then understand the viewpoint of the payers of the health system and how your product, how your startup can contribute positively to multiple stakeholders.

And then make sure that you're having the communication and engaging those stakeholders. So often people do things in healthcare without really working alongside the payers and then get frustrated when, you know what they've done isn't sustainable because of lack of payment. One of the things that we're very proud to have facilitated through SPROUT is one of our co-investigators her name's Alison Kirkman.

She developed a virtual care program providing wraparound services for medically complex children on Medicaid, and it provided immense benefit to these patients and their families. It also provided immense benefit to the payers. To the health system, right? Because it improved the care, reduced emergency department visits for these patients, it reduced hospitalizations.

The reason we knew that is because we as SPROUT facilitated an economic evaluation of that program, and we were able to demonstrate through evidence that it had this impact. And when the payers saw this impact that it had, which was, on the scale of millions of dollars, for a relatively small population. Their interest in promoting and supporting this program became astronomical.

And so Dr. Kirkman is now the founder of a startup. And I don't know if I can mention names of startups and whatnot. It's called Imagine Pediatrics. And it's dedicated to providing wraparound comprehensive care coordination and services for our most vulnerable populations for medically complex children on Medicaid, and it's being supported by a number of huge payers across the country who are incredibly interested in this work. And so that's one of the things we were able to really our work with SPROUT and our evaluation of the economic impact of this program. That's the reason that occurred, right? We had data on clinical outcomes. We had data on patient or on family satisfaction and on provider satisfaction, but what really drove this to become successful?

Was that data on cost savings. That's fascinating.

[00:38:57] Jared: I'm curious of also, cuz we've talked about value-based care quite a bit but what I'm not really quite sure of yet is where are we on the adoption cycle of this and in the broader health system?

[00:39:07] David: That's the answer to that is rather complex. It varies for pediatrics versus adults. We're much farther away from a value-based care approach for pediatric populations. And that makes sense because pediatric populations are generally lower costs and generally the improvements you can get from a value-based approach are things that may not be realized for years or even decades. It's a little bit more of a challenge for payers to jump into value-based care contracts in that sort of situation.

Again, why it was so important for us to demonstrate the value of that wraparound virtual care program. On the adult side, we're starting to see a lot of movement in that direction and the adoption's really accelerating fairly rapidly. I think the biggest challenge is, that although the interest and desire to move towards a value-based system is very high, all of our infrastructure within the healthcare system is still based on fee for service, meaning all of our financial systems, our accounting systems, the payers, accounting systems and financial systems, the payer's staffing,

the hospital system staffing is all tied in to a fee for service approach. Generally the healthcare institutions, they have the institution that has evolved through decades in a fee for service environment. And then they have the value-based care department or area, right?

That is constantly in that battle with how can we get our things prioritized but it's really important to prioritize those things because that's the direction that this really has to go. And so I think we are seeing movement in that regard, but again, I think the technology is really key to that because it offers opportunities to facilitate that movement forward and to make it easier to do so again, getting the to the ease of use.

And the ease of application is critical. The more we can make that transition, the easier path, the more likely we're actually going to see it happen.

[00:41:17] Ty: I've been curious about accountable care organizations is whether or not that's been a, it seems like that's been a mid step to try to get to value-based care.

Could you speak on that briefly here?

[00:41:27] David: I certainly don't wanna portray myself as an expert on accountable care organizations, but we've had some certainly have been engaged in a decent amount of the work in that space. I think it is a means of incorporating value-based care into the, a fee for service environment.

And It gets fairly complex in that regard cause you get into things like risk stratification of populations, and just a number of permutations and things that have to be done to actually generate, significant cost savings. And it's not just about how much money you save, it's about how much money you save relative to how much money you were expected to spend.

And that gets into calculating how much money you were expected to spend, which gets into the distribution of disease burden within your population. All of that gets into data, right? So one of the foundational elements of having a an effective accountable care organization is having a really good handle on your data and how you're managing that.

And this is how I'm pivoting this conversation into more of a health IT space. But this is where I have been more involved in it. I think the if you don't have good data, you cannot actually Conduct appropriate risk stratification. You cannot produce reliable metrics. It creates a lot of additional burden of work on multiple team members to be able to get that information and to demonstrate the savings that you're able to generate.

You may be doing a great job in the care that you provide, but it's not reflected in your metrics. So we have to make sure that we have very strong data infrastructure and reporting capability in order to facilitate the success of those programs. That's fascinating.

[00:43:15] Jared: I know we're getting close to the tail end of everything here.

We'll just have a couple more questions for you. And one of 'em is we always like to have you look towards the future to a more utopian mindset. And just for in your mind, what does the future of healthcare look like on the utopian side? What do you hope for it to look like with regards to your work in telehealth, digital health, value-based care, telemedicine.

[00:43:39] David: I think we're moving towards patients being more engaged in their healthcare and healthcare being more personalized, but having it also having those approaches be applied at a population level. The important thing that we really have to focus on as we move towards that is doing it in an equitable fashion.

Because I think one of the greatest risks that we have as this technology advances and as some of these amazing new tools are developed is that segments of the population get left behind. And I think as you design these systems, you have to think at the beginning. How you should design these systems with the disadvantaged populations in mind, with the non-English speaking populations in mind, not with the wealthy walking well in mind. You don't design it for the people who are fully have a high level of health literacy, a high level of digital health literacy, no disabilities, speak English and have an excellent broadband service to their home. And a home office, right? That's not who you should be designing these programs for.

You design 'em for the folks that don't have those advantages rather than trying to fit those disadvantaged populations in once you've already designed the technology. I think if we can do that, we can move towards personalized medicine. And population health management that benefits everyone where your level of digital health literacy, your level of general health literacy doesn't determine whether or not you can take advantage of this technology.

And I think that will require a very concerted effort on the part of the developers. It will require a concerted effort on the part of our clinicians, of our patient family advocates, of our policymakers, of our administrators, and really across the board. But I think that is a achievable vision if we can get to that level of coordination and collaboration.

And I think a huge part of creating that change is the research and the data that goes into proving out, why this works. And you've done such an excellent job of leading that charge. Something else that we like to talk about as well is, for those people that are trying to follow in your footsteps, they're trying to advance it forward after you and take the reins, even though you're still mid-career as well. What advice do you have to those up and comers in the field that are also trying to make changes?

Yeah, I think a key bit of advice that I would give is we're all on the same team, and that seems a little cliched and obvious, it's when you work across multiple stakeholders, when you work across healthcare administration, policymakers clinicians, family you really have to have a strong understanding of their perspective.

And you have to understand that, ultimately we're all working towards the same goals, which is improving the lives of our patients and their families and our communities. We may be taking different approaches to do that. Or have a different perspective on how that needs to be done, but really taking the time to understand those viewpoints is the path to actually reaching consensus.

I think too often people, groups, they draw battle lines and they dig in right to those stances, and they don't wanna budge because it's seen as somehow as a defeat and that in many ways is an oversimplification. It allows you to, it gives you an out to having to really think about other people's perspectives.

I'm somebody that embraces the complexity, and I think if you're gonna be in this space, you have to embrace the complexity. And that means you have to understand different people's viewpoints and understand why they feel the way that they do about a certain thing. Why they're pushing for the certain approach.

Because very often if you can do that, you can break it down to the core issues that need to be solved, and you can find that common ground in a way to approach it that will actually address everyone's concerns and make everyone, maybe not make everyone happy, but at least make everyone understand the value of the approach and agree to move forward.

So I think that's really, the key thing, we're all on the same team. Respect other people's expertise, and embrace it. You should always be learning. That's the other thing. If you're in a situation where you're having a disagreement or a conflict, it's an opportunity to learn and you should take it as such.

So I think that's a, I would love to see, folks that are coming up in this space, take that approach.

[00:48:25] Jared: That's incredible. Yeah. We're all in this thing together, oh yeah. Dr. David McSwain, thank you so much for joining us today. Thank you for your insights and perspectives, and just thank you for the work that you do.

We're excited to see the future of the space, thank you so much

for joining us today.

[00:48:37] David: Thank you. Thank you for having me on.

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