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00:00:00:29 - 00:00:23:14
Tom Haederle
Welcome to Advancing Health. The perinatal period is a delicate time for a new mom's mental health. In fact, 1 in 4 moms experiences perinatal depression and anxiety. Coming up, a look into how a leading specialty hospital for women and newborns developed a program that helps prevent perinatal depression.

00:00:23:16 - 00:00:44:29
Julia Resnick
Hi everyone. I'm Julia Resnick, director of strategic initiatives at the ���������� Association. I am so pleased to be here today to talk with all of you about perinatal depression. I'm joined by two experts from Women & Infants Hospital of Rhode Island. We have Shannon Sullivan, who is the president and chief operating officer, joined by Dr. Caron Zlotnick, who's the director of behavioral medicine research.

00:00:45:01 - 00:00:49:04
Julia Resnick
Shannon, Dr. Zlotnick, so happy to be here with you all today.

00:00:49:06 - 00:00:50:04
Shannon Sullivan
Thank you. Julia.

00:00:50:05 - 00:00:51:12
Caron Zlotnick, Ph.D.
Thank you for having us.

00:00:51:16 - 00:01:02:02
Julia Resnick
So let's dive right in. Shannon, I want to start with you. Can you start with some background on your hospital and your community?

00:01:02:04 - 00:01:37:21
Shannon Sullivan
Sure. Absolutely. So Women & Infants is one of the largest freestanding women's health hospitals in the country, exclusively dedicated to serving women and their families. We do about 8,700 deliveries annually. We have an 82 single bed level, 3 to 4 NICU with about 1,100 discharges annually. We have a comprehend of women's medicine program that includes an inpatient unit, GI, OB medicine, endocrinology, basically anything that cares for women during the course of their lifetime.

00:01:37:24 - 00:01:58:23
Shannon Sullivan
We are also the only OB hospital in the region that is an obstetrical tertiary care hospital. Plus, we have one of the largest NICUs in New England and actually on the East coast. So we care only for women here, only for women and their infants. And we feel really strongly about their care being really high quality.

00:01:58:25 - 00:02:16:09
Julia Resnick
That's amazing. And I love that whole life cycle from when they're young until when they're much older. And for this podcast, we're really focusing on your hospital's pregnancy and postpartum care. So how are you thinking about that whole continuum and making sure that that care extends to women after they give birth?

00:02:16:11 - 00:02:40:10
Shannon Sullivan
You know, I think it's important to note that even though I'm the president and chief operating officer now, my background is I'm a perinatal social worker. I've a master's in social work and I practiced in this setting for about ten years before I got into leadership. And so I can tell you, we're particularly dedicated to the pregnant and postpartum care, especially the mental health needs of women across the state.

00:02:40:13 - 00:03:12:03
Shannon Sullivan
And so, you know, currently, when you look at morbidity and mortality across the United States in the pregnancy and postpartum period, suicide and overdose are climbing higher in that list, and mark two of the top ten reasons that women get sick and die during their pregnancy or one year postpartum. It's a particularly delicate time for women and their families, and that's underscored not just by the data and the research but a lot of the anecdotal stories that you'll hear, you know, across news outlets.

00:03:12:03 - 00:03:38:12
Shannon Sullivan
And so it's incredibly important for us, being that we are a women's hospital, being the types of patients that we care for, that like I said, come from a wide variety of backgrounds. And given what we know about women in their pregnancy and postpartum period and what's happening nationally. And so there are not ever enough resources to care for women during this particularly delicate time during their life.

00:03:38:14 - 00:03:47:26
Shannon Sullivan
And so we've really spent a lot of time in the last 25 years investing both in the research and in the care of women.

00:03:47:28 - 00:04:04:27
Julia Resnick
I think what your hospital is doing is so important because it connects the research in this space with the care. So, Dr. Slotnick, you're an expert in this space. What were you seeing that helped, you know, it was so important for your hospital to do more around postpartum depression care?

00:04:04:29 - 00:04:34:22
Caron Zlotnick, Ph.D.
Well, my expertise and focus is preventing postpartum depression. When I first started at Women & Infants Hospital, which was, many, many moons ago, you know, Women & Infants has a large ObGyn clinic. The majority of their perinatal patients are on Medicaid. And this is a very high risk group of women who are at risk for postpartum depression.

00:04:34:24 - 00:05:01:08
Caron Zlotnick, Ph.D.
When I started at Women & Infants Hospital as a clinical psychologist, I treated many of these perinatal patients with mental health issues. So I heard firsthand the struggles of these patients with mental health issues. You know, we know society  - you could even look on Facebook - tells us that having a baby is the happiest time of your life.

00:05:01:10 - 00:05:20:00
Caron Zlotnick, Ph.D.
And, these patients really experienced a lot of stigma and shame around their mental health issues. You know, that got me thinking that, you know, screening and treatment is very important but prevention is better and more cost effective.

00:05:20:06 - 00:05:23:11
Julia Resnick
So talk to me more about that. What does prevention look like?

00:05:23:13 - 00:05:52:27
Caron Zlotnick, Ph.D.
Well, there's no proven or consistent way to predict who might be at risk for postpartum depression. You know, it's probably more cost effective to offer a prevention intervention like program to prevent postpartum depression to every pregnant woman rather than guess who may benefit from the program. So, the Rose program: Reach out, stay strong,

00:05:52:29 - 00:06:21:29
Caron Zlotnick, Ph.D.
essential for mothers with infants. So the overall aim of ROSE is to reduce suffering and increase joy for as many new mothers with an infant as possible during a time when which can be very stressful and lonely. The Rose program is administered during pregnancy, usually in small groups consisting of four sessions during pregnancy and a postpartum check-in post delivery.

00:06:22:01 - 00:06:54:22
Caron Zlotnick, Ph.D.
The ROSE program tries to focus on those risk factors that fall postpartum depression that are amenable to change. So the session topics focus on improving relationships and support system, effective strategies to communicate, like how to say no, how to ask for help. Very important in the postpartum period. Self-care strategies, ensuring that new moms have me time, that they don't get depleted. And goal setting.

00:06:54:25 - 00:07:27:17
Caron Zlotnick, Ph.D.
We also provide information on different types of stresses that can occur in the postpartum periods, you know, such as baby blues and what is involved with postpartum depression and how to identify it, we try to destigmatize it. It is a common struggle for many postpartum women. You know, 1 in 7 experience full-blown postpartum depression. We tell them how and where to reach out for help.

00:07:27:19 - 00:07:53:28
Caron Zlotnick, Ph.D.
To accompany our sessions, we have a patient workbook, which is available in English and Spanish. We did a very large implementation study in which we had 98 sites across the country, delivering Rose. So some sites delivered Rose virtually, others in person. Now, what is important with delivering Rose is that you don't need mental health expertise.

00:07:54:00 - 00:08:27:17
Caron Zlotnick, Ph.D.
So we had the full spectrum of people delivering Rose: clinic nurses, doulas, medical assistance navigators, community health workers, and actually mental health providers. And the training for those who want to deliver Rose is relatively an easy process. The ROSE website, which is hosted by Women & Infants, has all the training intervention materials. The training videos, as I mentioned before, the patient workbook.

00:08:27:19 - 00:08:38:08
Caron Zlotnick, Ph.D.
And Rose itself is highly scripted. So there's a scripted manual there. We have slides for virtual delivery and all free of cost.

00:08:38:11 - 00:09:01:27
Julia Resnick
That's amazing. And I think just having this publicly available is so hugely important. And also there are so many communities that don't have enough mental health providers that it's really powerful that you can be a lay provider or just a medical provider. I want to pivot slightly. I know that your hospital is doing work in perinatal depression and supporting postpartum women in their families beyond the Rose program.

00:09:01:29 - 00:09:05:20
Julia Resnick
Shannon, can you talk a little bit about what else is going on?

00:09:05:22 - 00:09:44:01
Shannon Sullivan
One of our more proud moments is how dedicated this organization has been to the totality of care of women. Not just their medical care, their psychological care, their socioeconomic care, their social determinants care. And really making sure that they support the whole woman in their family, for many decades now. And that is mostly our premier program, the one that, you know, Dr. Zlotnickwas just talking about, that she had started in is our day hospital program and our partial hospitalization program, which opened 25 years ago.

00:09:44:02 - 00:10:14:09
Shannon Sullivan
It was revolutionary at the time. I would argue it's still revolutionary today. It was a program for assessment and then care of pregnant and postpartum women with perinatal and postpartum depression. And what was so revolutionary about it is it was a program that allowed women to get that intensive outpatient care. So coming every day, but with their baby. Oftentimes you would find women were separated during treatment from their children.

00:10:14:09 - 00:10:42:01
Shannon Sullivan
And then, you know, psychiatrists, psychologists, social workers couldn't really assess bonding. They couldn't really assess how women were doing and caring for their infants as well, as it didn't allow women more time to be able to bond under the professional treatment that they received. So that was opened late 90s, early 2000s and still remains actually one of the only in the country and cares for a wide variety of women, really across the region.

00:10:42:03 - 00:11:04:09
Shannon Sullivan
And since that time, more recently, we've increased the amount of women and the types of care that we're providing. So it's no longer, you know, postpartum and perinatal anxiety and depression. We also have an OCD track. We found there's a higher prevalence, especially for women who've previously experienced obsessive compulsive disorder in the postpartum period. That can be a really difficult time.

00:11:04:11 - 00:11:28:13
Shannon Sullivan
So we've opened an OCD track to the partial hospitalization program, and most recently, within the last six months, we've reopened a substance use track so that we can, you know, try to work together. We work together with a Suboxone program. We have family medicine who's been coming in and helping us to care for not only the patients, but also the babies that are in that program with their mothers.

00:11:28:13 - 00:11:47:18
Shannon Sullivan
And so we're really trying to diversify the types of patients that we're caring for in that program, all along the lines of treating mothers while keeping them together with their children. It's really been well received within the community. We can't keep up with the volume as you can imagine, and so we're continuing to find ways to grow it over time.

00:11:47:21 - 00:12:14:09
Shannon Sullivan
Two other ways that we're really looking is Dr. Emily Miller, who's the division director of maternal fetal medicine here, has an RO1 grant for the Compass Plus program, which embeds social workers and case managers within obstetrical practices for that assessment, grief intervention and then referral. And then our newest program that we're most proud of that hasn't started yet is our mobile van program.

00:12:14:10 - 00:12:40:16
Shannon Sullivan
CVS Health recently gave us a grant to purchase a mobile van, and in that mobile van, we'll have a nurse practitioner and community health workers. What we know about our particular community is especially the patients that Dr. Zlotnick was talking about, our high Medicaid clinic onsite. It's hard for patients to get back. You know, you're asking them to deliver a baby and then they might not have reliable transportation, they might not have reliable child care.

00:12:40:22 - 00:13:12:18
Shannon Sullivan
And, you know, I will tell you, as the mother of three who had reliable transportation, who had reliable child care, getting out of the house with my children during that postpartum period was really challenging, especially to take care of myself. And so the postpartum van is going to be able to go out and really provide that care in communities to patients in their home and in the van, and be able to identify and then refer either to Rose or to Compass Plus or to the day hospital program when they're meeting with patients in their own community and really seeing what's happening in their home.

00:13:12:20 - 00:13:30:18
Julia Resnick
That's really amazing and impressive work. And please keep us posted on all of these new programs. It sounds like they'll be incredibly impactful. To wrap things up, I just want to pick your brains about what you've learned while implementing these programs, because I'm sure we have people listening who are thinking, how do I do this in my community and in my setting?

00:13:30:25 - 00:13:38:11
Julia Resnick
So what do you think those key takeaways are - that others could learn from your experiences to set up their own programs?

00:13:38:13 - 00:14:02:24
Shannon Sullivan
I think execution is always a problem and a lot of that has to do with, you know, these are complex clinics, these are complex patients. And everything, of course, requires resources. And all of those things make it more complicated. I would say that one size does not fit all for everyone. We've seen many people fail trying to implement a postpartum day hospital program.

00:14:02:24 - 00:14:30:19
Shannon Sullivan
We've seen many people with the best intentions. And so you have to partner with a wide, wide variety of people to get any of these programs off the ground. Your payer contracting teams, your operational needs, your clinical needs, your patient liaisons, your community health workers. And so it really does require a multidisciplinary approach to execution and probably much longer than any of us ever

00:14:30:19 - 00:14:42:21
Shannon Sullivan
like when it comes down to that. But I would say if you get the right multi-disciplinary team, embedded in doing your work, you can do it, but you certainly can't do it alone.

00:14:42:24 - 00:14:44:15
Julia Resnick
Anything to add, Caron?

00:14:44:17 - 00:15:16:00
Caron Zlotnick, Ph.D.
I can say the organization has to have the capacity to implement a program like Rose. What I would also like to say is that in recruiting potential sites, it was very heartwarming to hear from administrators, directors of programs really expressing a deep passion about improving maternal mental health. You know, in our study we realized that it makes a difference if you have a cheerleader.

00:15:16:02 - 00:15:48:24
Caron Zlotnick, Ph.D.
Best if leadership is the cheerleader but even those who are delivering Rose. And I just want to mention that on our website at Women & Infants Hospital, we actually have an implementation plan for agencies and hospitals that are thinking about implementing the Rose program. That really helps these sites to think through what it is that they need to do to successfully implement Rose or actually any program similar to Rose.

00:15:48:27 - 00:16:15:03
Julia Resnick
Fantastic. So I think three key themes that I heard was that you need passion, you need partnerships and you need patients. Shannon, Dr. Zlotnick, thank you so much for sharing this fantastic work that you're doing. To our listeners, you should check out the Rose program website on the Women Infants Hospital website. Thank you all for listening. And thank you again to Shannon and Dr. Zlotnick for your passion for this issue and for sharing your expertise with our listeners.

00:16:15:05 - 00:16:15:18
Shannon Sullivan
Thanks so much.

00:16:16:09 - 00:16:19:07
Caron Zlotnick, Ph.D.
Thank you for giving us this opportunity.

00:16:19:09 - 00:16:27:20
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:00:27 - 00:00:24:15
Tom Haederle
Welcome to Advancing Health. For stroke victims, speed and survival are closely linked. Quicker diagnosis and treatment can make a huge difference. Coming up in today's podcast, a look at how those two letters we hear more and more about in today's health care - A and I - artificial intelligence, are being applied to protocols for stroke treatment.

00:00:24:18 - 00:00:43:24
Tom Haederle
Hi everyone. I'm Tom Haederle, senior communication specialist with the ���������� Association and pleased today to get to do one of my favorite parts of this job. And that's highlighting the amazing work that goes on every day among our member hospitals and health systems. And here's a great example: the integration of artificial intelligence into treatment protocols for stroke victims

00:00:43:24 - 00:01:08:11
Tom Haederle
at Detroit-based Henry Ford Health. Joining me from Henry Ford to talk about this are Dr. Aaron Lewandowski, an emergency medicine doctor and the emergency medicine stroke representative at Henry Ford West Bloomfield Hospital, and Doctor Alex Chebl, a vascular and interventional neurologist and director of the Henry Ford Stroke Center and the Division of Vascular Neurology. Doctors, thank you both for joining us on this Advancing Health podcast today.

00:01:08:11 - 00:01:09:08
Tom Haederle
Appreciate you being here.

00:01:09:09 - 00:01:10:07
Aaron Lewandowski, M.D.
Thanks for having us.

00:01:10:09 - 00:01:11:10
Alex Chebl, M.D.
Thank you for having me.

00:01:11:12 - 00:01:20:03
Tom Haederle
Dr. Lewandowski, let's start with you and a basic question: why is speed of diagnosis and treatment so critical when treating victims of a stroke?

00:01:20:05 - 00:01:40:23
Aaron Lewandowski, M.D.
There's a common saying in neurology and stroke care that time is brain. It is estimated that millions of neurons are irreplaceably lost each minute during an ischemic stroke. So the sooner that we are able to diagnose and treat a stroke, the more brain we're able to save and the patients are able to have a easier outcome and a better recovery.

00:01:40:25 - 00:01:45:28
Tom Haederle
And what exactly does AI lend to the process? How has it improved how we're doing this now?

00:01:46:00 - 00:02:12:10
Aaron Lewandowski, M.D.
AI has been used in multiple ways across medicine. In stroke care particularly, we're able to use it in helping with diagnosis of stroke in a timely manner. Our program specifically is called Rapid AI. It is a software program that allows for quicker diagnosis of strokes and also facilitates communication between physicians. Dr. Chebl was actually the physician that brought the idea to our stroke committee, and we've been using it for approximately two years.

00:02:12:12 - 00:02:23:19
Tom Haederle
Does it actually paint - and this is a question for both of you - does it paint a picture of what's going on inside the stroke victim inside the brain actually allow you to see something you couldn't see before. Dr. Chebl?

00:02:23:21 - 00:02:44:01
Alex Chebl, M.D.
It's not so much as paints a picture as gives you an exact picture of what's going on. So the challenge we have in stroke neurology, unlike, say, when a patient comes in with a heart attack, you know, a patient grabs a chest, they're having chest pain. You can do an EKG and a cardiologist emergency physician can know immediately where the problem is.

00:02:44:03 - 00:03:08:12
Alex Chebl, M.D.
The trouble in neurology, is that there are many different types of stroke. Some types of stroke are caused by bleeding into the brain. But the more common type of stroke and why we use AI most commonly is called a ischemic stroke where there's a blockage, and the treatment for those two types of stroke are exactly opposite. One causes the other, and so you have to know what type of stroke you're dealing with.

00:03:08:18 - 00:03:17:15
Alex Chebl, M.D.
And this is why it's more complicated. And knowing what's going on inside the brain with the arteries is critical. And this is where the AI helps us.

00:03:17:17 - 00:03:52:12
Aaron Lewandowski, M.D.
Particularly with ischemic strokes, the issue is trying to figure out what part of the brain has been affected by the stroke and also where the blood clot is. And, is it amenable to intervention? There's medicines such as TMK which we're able to use to try and break down the clot during an ischemic stroke. But particularly where I used it for our purposes is in the use of the thrombectomy procedure, which is where you're able to intervascularly go up into the brain and actually remove the clot that's causing the stroke if it's located in an appropriate and amenable position.

00:03:52:15 - 00:04:15:02
Aaron Lewandowski, M.D.
So the program serves multiple purposes. The AI portion of the program evaluates the CT angiogram and the CT perfusion studies of the patient looking for any asymmetry in blood vessel distribution or perfusion. This is able to allow us to quickly evaluate for signs of what we call a large vessel occlusion. Those are the types of strokes that are most amenable to the thrombectomy procedure.

00:04:15:04 - 00:04:24:03
Tom Haederle
How much time has the use of Rapid AI shaved off of the diagnosis and allowed you to figure out accurately what's happening?

00:04:24:06 - 00:04:51:18
Alex Chebl, M.D.
Approximately 30 minutes. When we look at patients who are candidates for mechanical thrombectomy, that's the procedure where we pull the clots from the brain. We've reduced our door-to-puncture time. That is, from the minute the patient arrives in the emergency department until we actually puncture the artery to get to the brain, we've been able to save about 30 minutes, bringing us down to within the 90 minute ideal window for that treatment.

00:04:51:25 - 00:05:13:01
Alex Chebl, M.D.
But, just as importantly, it's also helped us with our door-to-needle time. So that balloon scan mentioned that you can also give the clot busting medication. That has to be given within 4.5 hours. And so we've now are consistently able to treat patients instead of roughly within an hour presentation. We're now being able to treat almost all patients with 45 minutes.

00:05:13:01 - 00:05:19:16
Alex Chebl, M.D.
And we're approaching 30 minutes from door-to-needle. And every minute is essential in that effort.

00:05:19:18 - 00:05:22:27
Tom Haederle
That's really impressive. What's been the impact on patient outcomes?

00:05:23:04 - 00:05:44:13
Alex Chebl, M.D.
Tremendous patient outcomes. If you look nationally, but also at our sites, you look at the number of patients, proportion of patients who recover to normal or nearly normal has increased. If you look at the number of patients who are discharged to home rather than to rehab, a good measure of whether patients have disability, that has also increased.

00:05:44:15 - 00:05:58:13
Alex Chebl, M.D.
And nationally, the data clearly support, this overwhelmingly so, so that the American Heart Association, for example, keeps shortening the time metric, because the sooner we do it, we're getting better outcomes.

00:05:58:15 - 00:06:17:21
Tom Haederle
Really good news for patients. I'm wondering, given the size of Henry Ford, a big, big system you have. And I imagine that rolling out any new technology or software or changing how things are done, particularly across a scale like that, has got its challenges. Did you run into any kind of bureaucratic obstacles or resistance? We don't know what this thing is . . .

00:06:17:21 - 00:06:21:23
Tom Haederle
Prove it to us. Was it hard to sell, or not really?

00:06:21:26 - 00:06:45:08
Aaron Lewandowski, M.D.
What? Dr. Chebl first brought the idea to us at the West Bloomfield emergency Department, it was certainly interest in, you know, ways that we can improve our stroke care. I would say overall, we didn't really experience any significant barriers to implementing Rapid AI here at Henry Ford. I would say the hurdles that we faced were the standard hurdles you faced with integrating any new piece of software or technology into your preexisting hospital system.

00:06:45:10 - 00:07:23:24
Alex Chebl, M.D.
Yeah, I would second that. You know, there was some trepidation amongst some team members. You know, our implementation of Rapid AI, there's many different ways that you could implement such a program. One could be it just notifies the radiologist, "hey, there's a potential stroke. Take a look." We have gone to the exact or most extreme or the deepest implementation, meaning all members of the team are notified when we have a stroke, and this has minimized the number of phone calls we have to make to get the patient ready, to get the OR team ready, etc. and when you have that many people learning something new there can be some trepidation.

00:07:23:24 - 00:07:44:12
Alex Chebl, M.D.
And the biggest fear really was, why do I have to have another app? And this is just going to increase my workload, right? I'm going to be bothered all the time with these unnecessary things. And in fact, it's the exact opposite. Most people got used to it. They could not believe that they were living without it. It's made their lives better.

00:07:44:12 - 00:07:49:11
Alex Chebl, M.D.
Not just the patients lives better. It made all of our lives better because it's simplified the communication.

00:07:49:14 - 00:08:21:26
Aaron Lewandowski, M.D.
And I would certainly second that. From an emergency medicine perspective, a lot of our job on a day to day basis is discussing phone calls with consultants and trying to communicate with other team members. So being able to have that initial phone call with the stroke neurologist to discuss the initial plan of care, but then everything else being in the, HIPAA secure chat with rapid AI has certainly allowed for our communication to be much more effective and much more quicker so that everyone can see in real time what's going on, what's the plan?

00:08:21:26 - 00:08:23:14
Aaron Lewandowski, M.D.
What are we doing for the patient?

00:08:23:16 - 00:08:44:22
Tom Haederle
Yeah. You hear that so often about applications of AI and in almost any capacity, ambient listening or anything else. People are delighted. It's a time saver and a work saver. And you've seen that with the with the implementation of, Rapid AI at Henry Ford. Any thoughts you would share about another system or hospital that is considering going around and maybe integrating it for the first time?

00:08:44:25 - 00:08:50:24
Tom Haederle
What would you say in terms of it's utility, in terms of its ease of use, that kind of thing?

00:08:50:26 - 00:09:17:29
Alex Chebl, M.D.
Well, I mean, I think there's two aspects. One is you've got to lay the groundwork for this. You need a stroke champion, champions. Certainly someone from emergency department is critical. You need someone on the neurology side. And they need to then sell this to everyone. Once you've laid the groundwork and you've got buy-in from everyone

00:09:18:01 - 00:09:41:20
Alex Chebl, M.D.
the actual implementation isn't that difficult. Securing IT, and the firewalls, etc.. The company helped set up. They also have individuals who can come and help train users. How to use it, how to adjust the settings, etc.. So we found that it was pretty straightforward to initiate the Rapid AI in our system.

00:09:41:26 - 00:10:00:29
Alex Chebl, M.D.
And one way to do it, I guess, would be my suggestion would be don't start too big. You know, maybe start if you have a large system like we have, you know, start locally, 1 or 2 smaller hospitals. Don't include every single team member. Get the bugs worked out of the system and then expand.

00:10:01:01 - 00:10:21:13
Aaron Lewandowski, M.D.
And definitely when you're trying to, you know, sell the idea to administration or other departments, certainly focusing on the benefits to patient care, like quicker diagnosis and also the benefits to the team members, such as more effective communication. I think is a really good way to show the positive benefits that can come from this.

00:10:21:16 - 00:10:47:18
Alex Chebl, M.D.
You know, obviously we do everything focused on the patient. We want the best patient outcomes, but we can't deliver good health care without paying for everything that's required to do so. So the money does play a role. And I think this is where it's important for an administrator to understand is that the better the patient does, the shorter length of stay, the less money is spent on that patient.

00:10:47:22 - 00:11:02:22
Alex Chebl, M.D.
And therefore a health system can keep more of that money for the other services that they need. And I think that's very important. I mean, after all, this is why we were able to convince CMS to pay for these very complex treatments is because overall it ends up saving money.

00:11:02:24 - 00:11:09:23
Tom Haederle
It's a great point, thank you. As we wrap up, any final thoughts? Anything we haven't talked about that you'd like to say about Rapid AI?

00:11:09:26 - 00:11:35:20
Alex Chebl, M.D.
You know, these systems now? Although they're mostly started in stroke, there are many competitors, Rapid AI as well, but they have other modules. And so these systems can be used for other disease states, pulmonary embolism, the identification of intracranial hemorrhage, cerebral aneurysms. And so there are many opportunities for multiple different departments to collaborate. And that can also help with the financial aspects of this.

00:11:35:21 - 00:11:46:14
Alex Chebl, M.D.
You know, the more users you have on board, it tends to be, you know, cheaper than just having each individual division having their own systems working independently.

00:11:46:16 - 00:11:51:12
Tom Haederle
That's a great point, thank you. Thank you for bringing that up. Dr, Lewandowski, any final thoughts?

00:11:51:15 - 00:12:09:23
Aaron Lewandowski, M.D.
I've certainly enjoyed the implementation of Rapid AI. It makes my job simpler. It provides better patient care. You know, I don't think that AI will ever replace physician assessment and judgment, but it's very impressive what a powerful tool it can be when used appropriately, to improve the care that we provide to our patients.

:12:09:26 - 00:12:21:22
Tom Haederle
Absolutely. Thank you both so much for your time today and this great discussion. And I hope it reaches a lot of ears and get some people thinking about just how powerful this tool is. So again, appreciate your time. Thank you for being on Advancing Health.

00:12:21:25 - 00:12:22:15
Aaron Lewandowski, M.D.
Thank you very much.

00:12:22:20 - 00:12:25:05
Alex Chebl, M.D.
Thank you. Have a wonderful day.

00:12:25:07 - 00:12:33:18
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:01:01 - 00:00:26:02
Tom Haederle
Welcome to Advancing Health. Cybersecurity is a risk. And because of that, a priority for all hospitals and health systems. In this Leadership Dialogue, Tina Freese Decker, chair of the ���������� Association, and John Riggi, AHA’s national advisor for Cybersecurity and Risk, discuss planning for cyber attacks, putting protections in place, navigating cyber threats, and rebuilding trust and confidence in the system

00:00:26:04 - 00:00:31:01
Tom Haederle
when cyber attacks do occur.

00:00:31:04 - 00:01:00:23
Tina Freese Decker
Hello, and thank you so much for joining us today. I'm Tina Freese Decker, president CEO of Corewell Health and the board chair for the ���������� Association. From data breaches to ransomware attacks to outages, cybersecurity affects patient safety and enterprise risk and is increasingly a strategic priority for hospitals and health systems. Planning for cyber attacks and putting the proper protections in place is key to ensuring sustainability, patient privacy and clinical outcomes.

00:01:00:26 - 00:01:34:22
Tina Freese Decker
So I am so pleased to have the ���������� Association's John Riggi joining me for today's conversation. John is an expert in this field, and he serves as the AHA's first national advisor for cybersecurity and risk. He joined AHA in 2018 after a long, distinguished 30-year career with the FBI. He brings with him tremendous experience in the investigation and disruption of cyber threats, as well as the unique ability to provide informed risk advisory services to hospitals and health systems.

00:01:34:24 - 00:01:41:26
Tina Freese Decker
So before we jump into the conversation, John, can you just tell me a bit about yourself so that our audience can get to know you a little bit better?

00:01:41:29 - 00:02:08:13
John Riggi
Thank you, Tina, so much for inviting me here today to discuss these topics, which unfortunately, as you said, top of mind for everyone. So when I ended my 30-year career at the FBI, I still wanted to be in a position to serve. I spent a lifetime doing that, and in my last role at the FBI, my job was to establish mission critical relationships with private sector, with critical infrastructure in the health care sector in particular.

00:02:08:15 - 00:02:29:22
John Riggi
That's when I had the privilege and honor to be introduced to AHA and Rick Pollack in talking about cyber threats. And that's when I really learned how critical a role that the ���������� Association served for the entire health care sector. I could send over, you know, an immediate urgent alert to the and with a single press of a button

00:02:29:29 - 00:02:56:16
John Riggi
5000 plus hospitals received that alert. 50,000 executives received it. So I understood at that point we needed to engage in that continuing relationship. And when I retired, fortunately for me, Rick Pollack in the team said, John, you know, we've been listening to you and we think cyber will be an emerging threat, going forward. Unfortunately, none of us realized how significant a threat it would be.

00:02:56:19 - 00:03:00:12
John Riggi
And so, again, my privilege and honor to be here with you today.

00:03:00:14 - 00:03:22:21
Tina Freese Decker
Well, we are privileged and blessed that you are part of the ���������� Association team, and you're helping us navigate so many of these issues that come forward. Let's start with kind of one of the underlying questions that I have. We've seen all these cyber and physical threats that have targeted hospitals and health systems. How have they evolved over the last, let's say, 7 to 8 years?

00:03:22:24 - 00:03:58:21
John Riggi
Yeah, unfortunately they've increased pretty dramatically. So not only are they increased in frequency, but also in complexity and severity of impact. So on the cyber front, we have seen a, for instance, in hacking of patient health information. In 2020, it was about 450 hacks impacting 27 million individuals, not inconsequential. Last year, last year with the Change Healthcare attack, we had 259 million Americans had their health care records stolen or compromised by foreign bad guys, by foreign bad guys.

00:03:58:27 - 00:04:24:17
John Riggi
If we add up the numbers, just since 2020, over 500 million Americans have had their health care records compromised or stolen. So, John, wait a minute. There's only 330 million Americans. That's the population. Meaning that every American in this country has had their health care records compromised more than once. But what really concerns us are the dramatic increase in ransomware attacks, which are often accompanied by data theft attacks.

00:04:24:19 - 00:04:51:12
John Riggi
So these bad guys, primarily Russian speaking, believed to be provided safe harbor by the Russian government primarily but not exclusively Russian, have increased these attacks so that the impact really is not only disablement of technology, internal networks get shut down, data gets encrypted, organizations are forced to disconnect from the internet has a very, very dramatic impact on care delivery.

00:04:51:15 - 00:05:18:21
John Riggi
So this resulting disruption, delay to care delivery and ultimately posing a serious risk to patient care and safety, not only for the patients in the hospital, but for the entire communities that depend on the availability of their nearest emergency department for life saving care, radiation oncology, so forth. So we've seen that evolve again very significantly, and one of the reasons I think it's evolved so dramatically.

00:05:18:23 - 00:05:30:21
John Riggi
Geopolitics is part of that. But I think on a very base level, we as a sector depend more and more on network and internet connected technology and data.

00:05:30:24 - 00:05:56:13
Tina Freese Decker
Very true. You know, I did a podcast earlier this year about trust and rebuilding confidence and trust and having that public trust in health care systems and hospitals. And when you have a cyber attack or an act of violence that targets hospitals, health systems, it impacts patients, like you said, it impacts staff and our communities. How can we go about building that trust and regaining that confidence when we have these instances occur?

00:05:56:15 - 00:06:06:23
Tina Freese Decker
And do you have some examples of stories or insights organizations have used that have helped them navigate those cyber threats and build that public trust?

00:06:06:26 - 00:06:32:07
John Riggi
Great question, Tina. And also on the on the violence side, unfortunately, as I wanted to mention as well, that's increased pretty dramatically to set the stage there. I was shocked, as a former law enforcement officer, to find out nurses are the second most assaulted profession outside of law enforcement. And, you know, we expect it as law enforcement officers to be engaged, confrontational engagements.

00:06:32:07 - 00:06:37:09
John Riggi
You're making arrests, but nurses who just want to deliver care to help people? Shocking.

00:06:37:09 - 00:06:38:19
Tina Freese Decker
It's sad and unacceptable.

00:06:38:23 - 00:06:58:27
John Riggi
Agree, totally. So I think how do we how do we get that trust in the community? I think one - and I think we've done a fantastic job with your leadership and the AHA - acknowledge the risk, acknowledge the threat. Let's not hide it. Let's not pretend it's not there. But then to take real steps to prepare and help mitigate the impact of these threats.

00:06:59:00 - 00:07:25:01
John Riggi
So now we see, on the cyber side, hospitals are actively working to develop better downtime procedures, better backup systems to help shorten the length of the impact and help recover more quickly. And work with the federal government. Exchange threat information across the sector with our partners in other sectors. And really understand if we're attacked, this isn't a stigma.

00:07:25:02 - 00:07:51:18
John Riggi
This isn't something that an organization failed to do. We're all in this together. And on the physical side, we're working very closely with the FBI to help develop resources to help identify and mitigate targeted acts of violence directed toward health care organizations. But most importantly, our frontline health care heroes, our frontline health care workers. And again, working with the community, this is all partnership with the community as well.

00:07:51:20 - 00:08:08:05
Tina Freese Decker
So I'm sure you have a top ten list of things that we could do to prevent these attacks. But if you could share the top three things that we should do to prevent these attacks and how we can be resilient. And when I say attacks, I'm talking cyber and physical. We have limited time, we have limited resources.

00:08:08:05 - 00:08:10:19
Tina Freese Decker
But what is the most important things that we should be doing?

00:08:10:22 - 00:08:36:21
John Riggi
I think the overarching umbrella that all the others follow under is leadership. And really looking at these risks, acknowledging them and ensuring that both cyber and physical risks are treated as an enterprise risk issue. And then within that, on the cyber side, making sure on the defensive side that you're following well known, well-established, recognized cyber frameworks, making sure you start there.

00:08:36:24 - 00:09:03:08
John Riggi
Second, really thinking about third party risk. What we have seen is that a majority, the vast majority of cyber risk, cyber attacks we face come to us through insecure third party service providers. Insecure third party technology and insecure supply chain. Doesn't negate us from our responsibility to do what we can, but we have to understand that. And then the third thing is ultimately prepare.

00:09:03:10 - 00:09:24:08
John Riggi
We must prepare for the attack. There's an often, I would say, overused expression in the cyber security world. It's not a matter of if, but when. It's true. But I would also change that a little bit about it's not a matter of if you will be attacked. The question is are you prepared? So focusing on resiliency and so forth.

00:09:24:10 - 00:09:55:13
John Riggi
And then with on the physical side, education of staff, leadership priority, and working with the FBI and local law enforcement to potentially identify ahead of an incident acts of targeted violence directed towards the hospital. And then working together as a community help mitigate and prevent that act. The police always want to respond, can respond after the FBI. But I can tell you from personal experience, we'd rather prevent a crime, prevent an act of violence than respond after the fact.

00:09:55:15 - 00:10:19:15
Tina Freese Decker
Agree. And I think that developing those relationships with local FBI, with local law enforcement is critical because you to your point, it's not if, but when. But we'd like to be able to prevent all of it. Having those relationships is key. So I know that the AHA has been working very closely with the FBI and some health care systems to exchange that threat intelligence and enhance collaboration across our sector

00:10:19:15 - 00:10:28:21
Tina Freese Decker
and with federal agencies. Can you share more about that partnership and how it has helped us in identifying and mitigating both physical and cyber threats?

00:10:28:24 - 00:10:51:26
John Riggi
Great question again, Tina, and thank you for highlighting what we're doing with the FBI. So on the cyber front, we've been actively engaged in cyber threat, information threat intelligence exchange. Both on a very technical level, exchanging what - without getting too technical - threat indicators, malware signatures and so forth, but also identifying big strategic threats that we may face as a sector.

00:10:51:28 - 00:11:19:23
John Riggi
So, for instance, working with the FBI, we helped identify last year a threat to the blood supply before it was on the government's radar. We helped the government understand that cyber attacks on hospitals are not just data theft crimes. These are truly threat to life crimes. So the federal government actually previously raised the investigative priority level of ransomware attacks on hospitals to equal that of a terrorist attack once they understood what the impact was.

00:11:19:24 - 00:12:00:17
John Riggi
We are working very closely with the famed Behavioral Analysis Unit of the FBI, the profilers that many books and TV shows and movies have been written about to develop resources to help hospitals identify targeted acts of violence, threats that are pending against hospitals, and again, help intercede, intervene and help prevent those attacks. We have a whole series of resources available on the first ever joint FBI and Joint Health Care Sector webpage. We're about to issue a manual coming out here within the next month or so, based upon, joint work with the FBI in the field on best practices and lessons learned to prevent these acts of violence.

00:12:00:17 - 00:12:06:08
John Riggi
So we have a robust, almost daily interaction with the FBI and other federal agencies.

00:12:06:10 - 00:12:25:15
Tina Freese Decker
It's so helpful to know that we have those robust partnerships at the national level, and then we can create it at the local level, and to make sure that we're all in this together to, help protect our patients and the people that we care for in our community. So that's wonderful. My last question for you is just one about how we look forward.

00:12:25:17 - 00:12:38:26
Tina Freese Decker
Can you tell us what you think about is going to happen in the threat environment for 2025 and maybe into 2026? What are those things we should be watching, looking out for? And is there anything positive that you can see?

00:12:38:29 - 00:13:11:18
John Riggi
I will let you know there is some hope. Talk about the realistic environment. Then we'll talk about where I see the hope. So first of all, I do believe that the frequency of the attacks may decrease, but I think the bad guys are looking to make a greater impact. We have seen them go after systemically important organizations that serves health care. Change Healthcare, for example. Last year, attacks against the blood supply. The year before they attacked - found vulnerabilities in a commonly used technology and software known as Move It.

00:13:11:21 - 00:13:41:03
John Riggi
By attacking that software, it gave the bad guys, a Russian ransomware group, were able to gain access to millions and millions of patient records. I do believe geopolitics will have a very significant influence, for better or worse, on the level of cyber threat we face. Depending on how we deal in the outcomes of our negotiations, of our diplomatic efforts with Russia, China, North Korea and Iran has the potential to mitigate or increase the cyber threats that we face.

00:13:41:05 - 00:14:08:19
John Riggi
And ultimately, again, third party risk, major, major issue. Where do I see the signs of hope? And there are signs of hope, folks. Honestly, I have never seen the sector come together to share threat information to prepare for attacks, best practices, lessons learned not only amongst the sector. We see channels of threat information sharing and best practice across with other critical and sectors, with the federal government.

00:14:08:21 - 00:14:45:26
John Riggi
We've had victim organizations, CEOs come out publicly. Dr. Leffler from University of Vermont, Chris Van Gorder from Scripps. We've had Eduardo Conrado from the recent attack against Ascension not only come out publicly, but testify before the UN Security Council last November about the impact of this Russian ransomware attack against Ascension. So what I see is hope. The fact we are banding together and with the government and I hope, as we did in the great fight against terror, international terrorism, we will come together in a whole of nation approach to help mitigate that risk.

00:14:46:01 - 00:15:09:17
John Riggi
Now, Tina, I know I've done a lot of speaking here, and if I may, and with all due respect, I'd like to ask you a question if I could. Tina, in your role, you have very unique dual role. You're CEO of a large health system, and you're also the chair of the ���������� Association board. So how do you think about cyber and physical threats for your own organization

00:15:09:19 - 00:15:11:20
John Riggi
but on a national level?

00:15:11:22 - 00:15:33:26
Tina Freese Decker
Well, I believe that cyber and physical threats must be prioritized. It's a strategic risk. We have to understand how we focus on it, and we have to significantly prioritize it and emphasize what we're doing there. Previously, maybe 5 or 10 years ago, it was just thought of as a technical issue. It's not that. It's how we operate. Because like you said, we're so connected,

00:15:33:26 - 00:16:01:07
Tina Freese Decker
it's critical infrastructure and we must make sure that we are coming together. So for us as an organization, we prioritize our efforts, our investments, our work on it, but also prioritize business assurance. So how do we operate and make sure that everyone understands all the key components and the lessons that you shared on this discussion today, but also when we've had conversations before, how are we making sure that we know those and our teams know those?

00:16:01:09 - 00:16:25:19
Tina Freese Decker
I think the importance of safeguarding sensitive patient data and ensuring the integrity of our systems cannot be overstated. And that applies for my organization, and that applies for all of our members throughout the ���������� Association. And so I think those are some critical points. As we think about this it is making sure that we are safeguarding sensitive patient data and ensuring the integrity of our systems, as we go forward.

00:16:25:19 - 00:16:59:14
Tina Freese Decker
That cannot be overstated. And as we do that, I think we all uphold that level of commitment to excellence that our patients and the people in our community want. So, John, thank you so much for your time today, for sharing your expertise. While we may not be able to prevent or mitigate everything, you have given us such great advice and we should make sure we take that down, but also listen to many of your podcasts that you put out or the Action Alerts that you sent through because they are helpful and direct and provide that great advice to move forward.

00:16:59:16 - 00:17:17:11
Tina Freese Decker
And I know that you are available to connect with all of our members if there is a specific situation, or they just want to learn more to make sure that we're better. So thank you, John, for being here. And thank you to all of those that have tuned in to this conversation. We will be back next month for another Leadership Dialogue.

00:17:17:13 - 00:17:25:24
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify, or wherever you get your podcasts.

00:00:01:01 - 00:00:30:06
Tom Haederle
Welcome to Advancing Health. Quality and patient safety are the twin engines driving the mission of every hospital and health system, and both clinicians and board members have an important role to play in achieving these goals. Coming up in today's podcast, we hear from two experts from University of Utah Health about some of the best ways to help board members understand the critical role they play in making sure that quality and safety are always foremost in the patient experience.

00:00:30:09 - 00:00:53:15
Nikhil Baviskar
Hi, I'm Nikhil Baviskar program manager, trustee services here at the ���������� Association. Today I'll be discussing the critical role the board plays in quality and safety. With me are Dr. Kencee Graves, who is the interim chief medical quality officer at University of Utah Health and is an associate professor of internal medicine, where she practices as a hospitalist and palliative medicine physician.

00:00:53:18 - 00:01:16:24
Nikhil Baviskar
Also with us today is David Calling, who has served on the University of Utah Hospitals and Clinics Board since 2016 and is currently vice chair and co-chair of the board Quality and Safety Committee. Dr. Graves, I'd like to start with you. You recently presented to the board at University of Utah Health on quality and patient safety, an extremely important topic now and always for board members.

00:01:16:29 - 00:01:19:18
Nikhil Baviskar
Can you give us an outline of that presentation?

00:01:19:20 - 00:01:51:22
Kencee K. Graves, M.D.
Thanks for having us. And I think this is a really important topic. So when I gave this presentation to our board, I was new in this role. And what I learned was people around me, our board, our staff, people did not really understand the nuts and bolts of quality and the details. And so one of the things I offered to do was a quality 101 session. And my intent in doing that was to make sure that the group I would be working with and I were starting on the same page, so we both knew kind of what was going on in the landscape of quality.

00:01:51:25 - 00:02:10:18
Kencee K. Graves, M.D.
So the content of my presentation really came from the questions I was being asked in my first few months in this role. And that is, what is quality? What is safety? How they are different. So what sets those apart? What are these ranking systems all about? Why do we do that? What are accreditation bodies, why do we do that?

00:02:10:20 - 00:02:22:05
Kencee K. Graves, M.D.
And then, what is a quality structure? So what are you responsible [for]? Who works for you, that kind of stuff. And so really that's what my outline was, was just the basics, what I consider the basics in quality.

00:02:22:07 - 00:02:38:29
Nikhil Baviskar
I think it's great that you, you did something where everyone starts at a level playing field. That sounds like a really wonderful way. I know that not everyone has the opportunity to do so, but definitely a good way to get everyone on the same page. Can you give us the response that you received from the board members to that presentation?

00:02:39:01 - 00:02:57:20
Kencee K. Graves, M.D.
Yeah, I do want to call out - when I started, I actually had really good support from our board members. And they told me that this is something that they wanted. And so I felt like I had an open invitation because Dave and our CEO said, hey, we really think people could use something like this. Would you be open for it?

00:02:57:20 - 00:03:15:20
Kencee K. Graves, M.D.
So they gave me the time. Many of them had been to the AHA and we used an AHA podcast by Jamie Orlikoff to kind of set the tone for that session. And so people went in with a really curious mindset. I actually did a Google survey after I gave the talk to make sure people learned and felt like it was valuable.

00:03:15:22 - 00:03:35:21
Kencee K. Graves, M.D.
The feedback I got were that people felt like they knew more about quality after this session than they did before. They loved hearing about what we did at the U. They really felt strongly about supporting quality and supporting our leadership and driving toward high quality care, and they wanted to know how they could be more involved.

00:03:35:23 - 00:03:44:27
Nikhil Baviskar
So, David, question for you as one of the University of Utah Health board members, what was your reaction to this presentation?

00:03:45:00 - 00:04:03:12
David Colling
Yeah, Nikhil, what I would say is a couple of things, a few things that Kencee mentioned. But also remember, community board members typically are not clinicians, they're not health care employees, so this is a bit of a foreign environment for them. And that's part of the point, right. To have community board members get, you know, to offer a different perspective.

00:04:03:14 - 00:04:22:09
David Colling
But what can happen is, as a board member, you can get pretty overwhelmed pretty quickly with whether it's the acronyms, the accreditation, you know, all the different things Kencee trained on can be pretty overwhelming for community board members. So, I thought it was excellent. And once again, I want to reiterate, it was really a 101. Kencee

00:04:22:09 - 00:04:40:02
David Colling
didn't take any for granted, whether it was an acronym or a word, something need to be defined. It was really quite effective in the way that she approached it. You know, the other thing I think is it helped us continue to elevate quality and safety, you know, as a really important topic for the board. Right? So this is not a sideline.

00:04:40:09 - 00:04:55:17
David Colling
This is a really, really important really the driving force behind the board. You know, maybe besides finance and some other things, you know, a really important piece of piece of the work that we do. So I think there's a couple of things, that I reacted to. And frankly, I've been a board member for, as you mentioned, almost ten years.

00:04:55:19 - 00:05:03:13
David Colling
And I learned a lot. So what does that tell you? Right. So I think it's good for existing board members and new board members.

00:05:03:16 - 00:05:14:01
Kencee K. Graves, M.D.
I think it was a really important launching point for the CMS structural measure that requires patient safety to be part of board meetings. That would have been difficult if we had not done already the Quality 101 session.

00:05:14:03 - 00:05:35:29
Nikhil Baviskar
Thank you for mentioning that. What you're referring to as quapi, we're seeing a lot of folks, other boards that are realizing this is something that has to be integral to the planning process and the strategic planning process. David, I wanted to ask you, a follow up on that. So as the co-chair of the Board Quality and Safety Committee, you said you learned a lot.

00:05:36:01 - 00:05:46:01
Nikhil Baviskar
Do you do you feel like Kencee's presentation sort of set maybe an agenda or help you and your other co-chair plan going forward?

00:05:46:04 - 00:06:02:13
David Colling
Yeah. I mean, again, it gave such a good foundation, and I liked what Kencee said about us all being on the same page. So I do, I think it's set an excellent foundation for the committee moving forward. Got us all kind of in the same spot, whether you'd been there for ten years like myself or whether you're a brand new community board member.

00:06:02:15 - 00:06:19:22
David Colling
You know, the other thing I thought it was nice to, you know, we had it wasn't just board members. It was the clinical and health care staff there as well. I think it's important for them to listen to the dialog, understand that should help them understand kind of that knowledge gap, whether it's quality and safety or whether it's other, you know, board activities.

00:06:19:22 - 00:06:32:15
David Colling
You know, the community board members do need to be constantly reminded of definitions and things that come naturally to clinicians and health care workers, that that we need to continue to, to bridge that knowledge gap. So, yeah, absolutely.

00:06:32:17 - 00:06:43:01
Nikhil Baviskar
So as you know, this podcast will be listened to, by other board members. David, can you give some nuggets of wisdom or some advice to other board members that may be listening?

00:06:43:04 - 00:07:04:06
David Colling
Yeah for sure. So again, going to reiterate 101 basics. You know, don't take anything for granted. Don't make any assumptions. Assume that you're starting with everyone that knows very little about, you know, not necessary quality and safety, but certainly quality and safety in the context of the health care environment. I'd highly recommend making it interactive, almost a Q&A ongoing, right?

00:07:04:06 - 00:07:23:12
David Colling
So in other words, and I think we did that, you know, we never have enough time in our board activities. We probably could even have allotted more time. But as opposed to a report out on a presentation with Q&A at the end, and we did some of this, I would argue we could have even done more with this kind of back and forth discussion with the community board members asking further questions.

00:07:23:16 - 00:07:41:15
David Colling
Kencee being able to elaborate a little bit more, potentially even the health care folks and clinicians in the room adding a little bit of color. And we did some of that but I would encourage that. And once again, I would make sure that you include all certainly all community board members, regardless of tenure. You know, there might be the occasional one that feels like they know it.

00:07:41:15 - 00:08:01:11
David Colling
I'd be amazed if, if a community board member, no matter how long you've been serving didn't learn something from the presentation. And once again, I would say the entire board should be included, that dialog is healthy and I think creates good understanding amongst all parties. And you know, Kencee, you mentioned the podcast that that we kind of did a pre-work.

00:08:01:12 - 00:08:20:28
David Colling
You know, we asked everybody to listen to Jamie's podcast, and I want to say that was about a 30 minute give or take podcast, excellent foundation to reinforce the importance of quality and safety, right? So before we go into the 101 and the teaching piece, get everybody on the same page of the importance of it and the role it plays with the board.

00:08:20:28 - 00:08:29:10
David Colling
So I thought that was excellent. You know, I'll call it pre-work and everyone should kind of be required to listen to that I think prior to the actual presentation itself.

00:08:29:12 - 00:08:46:16
Kencee K. Graves, M.D.
I'm really glad you called out some of the interactive stuff and the keep it fun. I don't know if there's any chief quality officers listening, I do think that's an important piece. And so a couple things that I did that I thought worked really, really well. Survey questions after sections of my presentation. So I would talk about patient safety.

00:08:46:16 - 00:09:04:11
Kencee K. Graves, M.D.
And then I would ask people what it is. And then I would give them four multiple choice questions. Put one in there that was funny. And that kind of thing kept people really engaged. I also put together a laminated front-and-back about what ranking system that we use at the University of Utah, and explained every section of that.

00:09:04:14 - 00:09:23:11
Kencee K. Graves, M.D.
I went through my office and introduced people and talk about what they did, and that's the kind of stuff that people loved. They loved getting to know who their leaders are, and they really liked the human part. And I think that's critical because we're here for humans, right? Like quality care is for humans. And so that was kind of my undertone.

00:09:23:11 - 00:09:24:29
Kencee K. Graves, M.D.
I'm glad David picked up on it.

00:09:25:01 - 00:09:42:16
David Colling
And Nikhil, I'll just add one more comment to that. Yeah, the structure within the organization where quality and safety fits, the different roles. Again, something I kind of knew but didn't know in that level of detail. There's quite a bit more to the quality and safety than many would imagine. So I thought that was know really well done.

00:09:42:16 - 00:09:58:17
David Colling
You know, Kencee, I don't know if I've mentioned it to you, but I think that presentation it's interesting is I went back and reviewed it. That almost needs to be kind of a continuous piece of reference material. I almost feel like I want to make it a little less of a PowerPoint and more of a reference piece. So there's an assignment for you.

00:09:58:17 - 00:10:16:07
David Colling
But, you know, because it is so well done. It should be a continuous reference, you know, that's almost in your little in your toolbox as a community board member, because this is how busy we as committee board members are. You know, we've got our day jobs and we get so focused. So that presentation, which was extremely effective was only a few months ago.

00:10:16:09 - 00:10:30:20
David Colling
But when I reviewed it, you know, even prior to this, discussion, I was like, oh yeah, I need to, you know, keep remembering this kind of thing. So I'm going to be referring back to that pretty regularly. So that might be another piece of advice, you know, use it as an ongoing resource for the for the board.

00:10:30:22 - 00:10:48:28
Kencee K. Graves, M.D.
That's really good advice. And I want to go back to a point you made earlier where our accreditation partner is, that Det Norske Veritas or DNV. They were on site at the end of January. And so I reported that out to the board in February, and I included what DNV stands for and what it means and what they gave us citations on.

00:10:48:28 - 00:11:07:27
Kencee K. Graves, M.D.
And I used graphics to demonstrate kind of each bucket. And I did have people that have worked at the University of Utah in leadership for more than a decade come up and tell me, thank you for doing that, because I think quality is such an alphabet soup that for those of us who work in it, it's easy to forget that it doesn't mean a lot to anybody else.

00:11:07:27 - 00:11:16:23
Kencee K. Graves, M.D.
And so I would just say, I think it's really, really important to continue to revisit those abbreviations that may not land well without an introduction.

00:11:16:25 - 00:11:35:05
David Colling
And Kencee, I would say that the entire clinical or healthcare environment, health care environment is a big alphabet soup. If I had one advice for, you know, the clinical and health care staff, beyond quality and safety, there are acronyms and short you know, wordings used for things that just don't come natural to community board members.

00:11:35:05 - 00:11:38:06
David Colling
So I think that's a good reminder beyond quality and safety as well.

00:11:38:08 - 00:11:59:03
Kencee K. Graves, M.D.
Yeah, I've spent a lot of time talking about what I think chief quality officers should do. But I'll tell you what I think has been valuable to me as interim chief quality officer with a board. The board members ask really good questions. And for me, that is my check on. Am I explaining something well? What does an average patient hear and think and see?

00:11:59:03 - 00:12:17:24
Kencee K. Graves, M.D.
And how do they perceive us through the media? And what does the community say? And that is incredibly valuable because there are not a lot of spaces in my life where I hear that because I work in health care, I work around other doctors and nurses and the community board is my window to what the rest of the world sees when they see our health system.

00:12:17:27 - 00:12:37:28
Nikhil Baviskar
That's very helpful. As you said, the board should reflect the community and that's really important. You know, Kencee or Doctor Graves, I'll ask you just one more thing. For the board members listening, I already asked this to David, but what do you think that the board member should take away when it comes to, you know, working on quality, understanding it and learning about it?

00:12:38:01 - 00:13:01:02
Kencee K. Graves, M.D.
Part of that is, is what I said in that ask questions, stay engaged. And so if you see something or hear something that doesn't make sense, ask about it. The other thing that our board has asked me to do, which I found very, very helpful, is if I bring them a problem they've also asked me to report on who is responsible for it, what is the fix and when do I report back?

00:13:01:05 - 00:13:23:29
Kencee K. Graves, M.D.
And that cadence has kept me giving them information that is meaningful. And then also they've learned to trust the information I bring them. It keeps me honest and keeps a closed loop communication. So I think that's been really good. I do think it's possible to skim over things, and I would just say, I think board members can and should ask really really good questions.

00:13:24:01 - 00:13:35:08
Nikhil Baviskar
Well, thank you both so much for your time. This has been an awesome discussion and we really do hope that you know, your quality journey just continues getting better from here on out. So thank you again.

00:13:35:11 - 00:13:36:04
David Colling
Thank you.

00:13:36:07 - 00:13:38:16
Kencee K. Graves, M.D.
Thank you for having us.

00:13:38:19 - 00:13:47:00
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.

00:00:01:01 - 00:00:26:19
Tom Haederle
Welcome to Advancing Health. Ambient listening technology is coming into wider use as a way to keep accurate records of the conversations between doctors and their patients. In today's podcast, we hear from two senior executives with the Cleveland Clinic about how their integration of this new application of artificial intelligence makes for better clinical notes and leads to a better experience for everyone.

00:00:26:21 - 00:00:55:20
Chris DeRienzo, M.D.
Hi, this is Dr. Chris DeRienzo, AHA’s chief physician executive, and I am very excited for today's podcast. We get to have a conversation about AI enabled solutions in health care, and we get to have that conversation with two individuals who are leading the way at the Cleveland Clinic. We have both Rohit Chandra, PhD, executive vice president and chief digital officer for the clinic, as well as Dr. Eric Boose, he's a family medicine physician and the associate CMIO for Cleveland Clinic.

00:00:55:23 - 00:01:14:12
Chris DeRienzo, M.D.
We're going to have a broad ranging conversation today. But, folks, just before we get started, I've been out on the road a lot. And I have heard from health system after health system who is implementing this ambient listening technology about the kinds of transformative outcomes that they're experiencing. And now we get to talk to folks who are seeing that firsthand.

00:01:14:12 - 00:01:31:20
Chris DeRienzo, M.D.
And so, Rohit, perhaps the first question is to you, as the clinic begin to think about this universe of AI enabled solutions and ambient technology, what drew you to that as an offering that you wanted to get integrated into practice, you know, as quickly as possible?

00:01:31:23 - 00:01:46:27
Rohit Chandra, Ph.D.
So thanks, Chris, for the question. I think that our belief is that over time, AI has the potential to impact multiple aspects of health care all the way from clinical to back office and everything in between.

00:01:47:00 - 00:02:18:16
Rohit Chandra, Ph.D.
The thing that is particularly intriguing about ambient solutions is that they hit a critical pain point for physicians, and they have the potential to do it in a way that is safe. So ambient listening hits a pain point where physicians often spend multiple hours a day in documentation tasks. Those are obviously necessary from a regulatory and patient care perspective, but they take a lot of time. And the technology is almost perfectly suited at streamlining that burden.

00:02:18:18 - 00:02:27:00
Rohit Chandra, Ph.D.
The second part of it is it can be done safely and make sure that there is human oversight so that there is no risk of any patient harm.

00:02:27:02 - 00:02:38:21
Chris DeRienzo, M.D.
Let's talk about implementing this kind of a solution a little bit, because I couldn't agree more of the potential for safe, and better experience is huge. But this isn't the kind of thing that you can just turn on.

00:02:38:21 - 00:02:50:15
Chris DeRienzo, M.D.
And so, Eric, perhaps this one to you. When you made the decision, yes, we want to pursue this technology, we want to get it into the documentation arms of our clinicians. How did you begin that evaluation process?

00:02:50:17 - 00:03:07:03
Eric Boose, M.D.
Yeah, we know that there's quite a few of these software companies that are out there on the marketplace now. And so we want to make sure we found the right one for us. Isro had said we want to make sure it's safe, the content is appropriate. It's really helping the physicians and not being a hindrance to their day or some new technology that's being imposed on them.

00:03:07:06 - 00:03:27:18
Eric Boose, M.D.
So we actually took the route of doing several pilots. We actually worked with five different ambient vendors to see which one would work well for us. We had about 50 physicians in each of those. We kind of jokingly called it like a "British Bake Off," because we were kind of having comparisons going on between five different softwares, but we thought it was important to make sure that we chose the right one for us.

00:03:27:20 - 00:03:41:28
Eric Boose, M.D.
And just like choosing a car, you could go with that first one. It seems to work pretty good and you'll take it. Or you want to look at a variety and really make sure that the choice you're making is a good one, because it's going to be a major decision going forward. So we actually had a lot of fun with that.

00:03:41:28 - 00:04:05:15
Eric Boose, M.D.
We saw a lot of different aspects of ambient software. What's available out there on the marketplace, which ones worked well? And got a lot of feedback from our pilot users. And everybody was just so excited about this technology. The idea of going from being a lot of data entry, which was a big disruptor when the HRs came on the marketplace, to having something actually doing the work for you and doing it well was super exciting.

00:04:05:17 - 00:04:13:04
Eric Boose, M.D.
And to your point, you know, thinking about the idea of not having to spend the extra hours and all this documentation and focusing on other patient care we'd like to do.

00:04:13:06 - 00:04:22:24
Chris DeRienzo, M.D.
Amen. I imagine so five different solutions, 50-ish clinicians per solution. How did you pick where to go and who to work with and which sites to do?

00:04:22:26 - 00:04:49:09
Eric Boose, M.D.
Yeah, I mean, we had a whole evaluation process. A lot of the things you might think of when you're trying to determine if a tool like this would be appropriate for your organization. And one of them is, you know, around documentation, we want to make sure, first of all, they're not having to spend as much time documenting or getting that documentation done in a more timely fashion, getting home better, you know, in the sense of like less time after work hours or spending more time with our family or things that you want to do rather than doing all this extra work after hours.

00:04:49:11 - 00:05:06:03
Eric Boose, M.D.
But we want to make sure the quality was there. So we worked with our, you know, audit folks to make sure that the notes were looking good. We were tracking what the physicians were doing, how often they were using it, what they recommended. We did some surveys around, before and after, you know, do you feel like your cognitive load is less?

00:05:06:03 - 00:05:25:08
Eric Boose, M.D.
Do you feel a little less burnout? Basically, do you feel more comfortable and kind of enjoying medicine again, being able to sit there, not be worried about taking notes through the whole visit, but just having that face to face conversation that we all enjoy, including the patient. The patient certainly  notices, too. Everybody seems more relaxed and it's just been going so much more smoothly.

00:05:25:10 - 00:05:42:14
Chris DeRienzo, M.D.
That really hits home. I remember I had this spectacular family practice physician when I was, in western North Carolina, and he could, stay totally engaged in the entire visit while continually typing away at structure documentation. And he's sort of a unicorn. There are obviously other doctors who can do that, but most of us can't do that.

00:05:42:17 - 00:05:56:28
Chris DeRienzo, M.D.
And so, you know, hearing that you walk through this very purposeful and intentional evaluation process. Rohit, I'm curious. How did you ultimately decide on which solution to implement? And then, what approach are you taking the implemented?

00:05:57:00 - 00:06:08:08
Rohit Chandra, Ph.D.
So, a couple of comments. One, I think that traditionally humans have to overextend themselves to adapt to technology and that was sort of the journey with the EHR.

00:06:08:11 - 00:06:40:14
Rohit Chandra, Ph.D.
The thing that's intriguing about these ambient solutions is that the technology increasingly adapts to the human interaction, and that's the appeal. So just wanted to sort of get that out there. In terms of actually piloting and then deciding what technology to go forward with, we feel that this capability is the start of a transformation journey, and we hope that this is a big decision that if you make a good decision will be transformative over time.

00:06:40:16 - 00:07:02:28
Rohit Chandra, Ph.D.
What that translated into was a little bit of an approach that I have in bringing technology into the organization is "try before you buy." So that's what led us to say, hey, it's important for us to pilot something as opposed to just pick a partner based on sort of a superficial assessment. So I look back and say, I'm glad we did the pilot.

00:07:02:28 - 00:07:23:29
Rohit Chandra, Ph.D.
We got a chance to test drive multiple technologies by hand and there's no substitute for that. And at the end of it, then you're far more confident in your solution and the capability and the potential that it has. In terms of actually piloting five vendors, we piloted with what we thought were sort of key players in the space.

00:07:24:01 - 00:07:44:23
Rohit Chandra, Ph.D.
I am told that there are more than 100 different companies doing it, so. Goodness! Exactly. How many survive? How many find different variations? Time will tell. But at least we try to apply some judgment on which are the prominent ones that we should test drive. Like Eric alluded to, we looked at a few different criteria.

00:07:44:25 - 00:08:13:06
Rohit Chandra, Ph.D.
First and foremost is the product capabilities, the quality of the transcriptions, the ability to deal with multiple languages, the ability to attribute the right conversation to the right person in the room. All of that is technology capability that needs to be done right. The second part of it is the quality of the summaries that are generated, whether for the patient, whether for the physician, all of those. You need revisions...

00:08:13:06 - 00:08:23:14
Rohit Chandra, Ph.D.
how accurate and how complete is it? is a second consideration. Integration with the EMR so that the workflows are relatively smooth and not cumbersome is essential.

00:08:23:21 - 00:08:33:16
Chris DeRienzo, M.D.
Let's pause there for a second, because I know there are many different possible solutions. But as we get into sort of the next part of our conversation, which solution did you ultimately go with?

00:08:33:16 - 00:08:40:15
Chris DeRienzo, M.D.
And then what is the EMR platform that sits on top of just so listeners can have sort of a sense of, okay, this is what their environment looks like.

00:08:40:17 - 00:08:55:25
Rohit Chandra, Ph.D.
I can get some of the basics, and then I'll defer to Eric to speak to the experience. So we're an EPIC house. Our EMR is EPIC. And it was obviously essential for us that the workflows that the physicians encounter are as seamless as possible.

00:08:56:01 - 00:09:01:15
Rohit Chandra, Ph.D.
And I'll defer to Eric to speak to that part of it. But that was obviously an important part of our assessment.

00:09:01:17 - 00:09:19:00
Eric Boose, M.D.
Yeah. So in the end, when we went through our different assessments, we ended up with ambiance as our solution for our ambient AI software. I do think there's something about ease of use for the user, right? Just like any other technology, if you throw in too many barriers or make it too complicated the uptake is much lower.

00:09:19:02 - 00:09:42:17
Eric Boose, M.D.
All of these softwares in general are pretty elegant in their solutions in the sense that the listening of the visit all tends to occur on a phone that's listening through an app. But how it gets into the EPIC or whatever your EHR might be, the ease of use of having it there as a draft so that at that point can be reviewed, edited, added, subtracted before it's obviously accepted in the medical record was very important to us.

00:09:42:19 - 00:09:55:25
Eric Boose, M.D.
And so ease of use in the integration doesn't have to be fully, deeply integrated. I wouldn't say, but it has to be nice and elegant so that things go through so quickly and smoothly that the uptake is done. And it's very easy to use.

00:09:55:27 - 00:10:03:06
Chris DeRienzo, M.D.
And from the integration perspective, it's not just free text getting ported in. There are structured components to it that also have to get completed. Is that right?

00:10:03:09 - 00:10:23:04
Eric Boose, M.D.
Correct. I mean, as the recording is in the AI software is working, it will bring back the note and all the different sections that you would need. So the HPI, API and results and erroneous systems is also as patient instructions, which actually turned out to be one of the surprises that we found very valuable was that as soon as the AI was done, it created the note.

00:10:23:10 - 00:10:34:20
Eric Boose, M.D.
You could have the patient structures ready for them before they even left the exam room. Wow. And to have kind of like that written record of all the things I asked them to do, it was so nice for them as they left, having those instructions with them.

00:10:34:22 - 00:10:46:09
Chris DeRienzo, M.D.
You're about a month since announcing partnership in the move forward. How's it going? What kind of outcomes are you seeing? Well, you know, what do you what are you focusing on now that it's going live across the clinic?

00:10:46:12 - 00:11:03:25
Eric Boose, M.D.
I mean, it's been very exciting. We just started the implementation on March 10th. We did listen to our vendor ambiance a little bit, guiding us the way, you know, what's been successful for implementation across a large enterprise to start. And we work together also with our Cleveland Clinic culture to make sure how was accepted and brought forth to all of our providers.

00:11:03:27 - 00:11:20:10
Eric Boose, M.D.
There are several thousand in scope to be using the product, and so we decided to do things in waves. Ambiance gave us some advice about which they felt which specialty models were ready to go out of the box, which ones they might need about, you know, 4 to 6 weeks to get really tuned up and some other ones that took about 12 weeks.

00:11:20:12 - 00:11:40:07
Eric Boose, M.D.
So we're like, that's fine, we'll spread out the waves, so we'll launch as many as we can in wave one. And then move on from there. And we've actually within two weeks have about 1500 trained and almost a thousand using it already. We're getting feedback, you know, it's life changing. I love this product. I don't know how I survived without it.

00:11:40:09 - 00:11:41:00
Chris DeRienzo, M.D.
Oh my goodness.

00:11:41:00 - 00:11:57:09
Eric Boose, M.D.
We can all attest that it's been a struggle these days, right? We have a lot of information coming to us. We have a lot of patient expectations about getting back to them as quickly as possible. All this electronic health record and patient portals and just, you know, it's expected to be very quickly going through information and getting back to them.

00:11:57:11 - 00:12:15:16
Eric Boose, M.D.
So this really helps us in our day in the sense of things happened so quickly with it that it's really unloading the other processes that we have to do during the day. And we're feeling that relief and we're seeing some of the docs saying, you know, I don't know if I'm going to cut back my time like I thought it was going to, or I may postpone retirement for a couple more years.

00:12:15:16 - 00:12:31:00
Eric Boose, M.D.
I mean, things you would never think you would hear from physicians, right? This is like a technology they're asking for and begging for. Like, it was so interesting during the pilots. If there was a person that was in the office using it, yet three others weren't, they're all like, I want it. When can I get it? So that kind of energy has been building.

00:12:31:00 - 00:12:37:03
Eric Boose, M.D.
And so when we launched it and advertised it, everybody was very, very excited about it. So it's been it's been going very well.

00:12:37:06 - 00:13:01:20
Rohit Chandra, Ph.D.
Chris, I'll add a quick comment, which is most times technology is a little bit clunky to adopt and integrate, and understandably so. That's true for all of us as consumers. The nice thing was this technology's the integration and the ability to use it is pretty seamless. And the appetite and the enthusiasm for adopting it is unprecedented.

00:13:01:22 - 00:13:06:27
Chris DeRienzo, M.D.
It's pretty rare for me to hear a positive, life changing story from a technology implementation.

00:13:06:27 - 00:13:27:26
Chris DeRienzo, M.D.
But you've got it. And to be clear, like, this is the story I'm hearing everywhere. Health care is and will always be a uniquely human experience. And the more opportunities we have to thread our humanity back into the practice of medicine using this needle of technology, the better. We are just about out of time. As expected, this has been a fantastic conversation.

00:13:27:28 - 00:13:46:18
Chris DeRienzo, M.D.
I am curious, though, as your ambient rollout continues through its the thousands of providers who are pulling to try to get to use it. What else do you see on the horizon with this kind of potential impact? And where are you sort of looking down the road towards other potential AI enabled use cases?

00:13:46:20 - 00:14:04:10
Rohit Chandra, Ph.D.
I'll touch on a couple of things, which is we are currently rolling out ambient listening in outpatient settings. I think there's an opportunity to look at other scenarios and use cases in different settings where ambient technology can help streamline the documentation burden.

00:14:04:13 - 00:14:22:04
Rohit Chandra, Ph.D.
I think the second part of it is while today we are leading with transcription and summarization, I think there's an opportunity to bring greater clinical knowledge to bear that can perhaps serve as a physician's assistant at their elbow, helping streamline more and more mundane tasks as we go forward.

00:14:22:06 - 00:14:38:10
Eric Boose, M.D.
Yeah. And I think just to echo that, I kind of picture that as well - as sort of having this kind of copilot, you know, with you. Again, we have so much information we're trying to gather before we see a patient and deal with after we see a patient with testing, that I almost see it as like, could the AI bring everything together, like do a chart review?

00:14:38:10 - 00:14:58:16
Eric Boose, M.D.
What care gaps do they have? What are actionable findings that may need to be promoted to make sure they follow up on? Almost like a patient briefing that when I open that record, tell me what I really need to know going into this visit to make sure that I take care of that patient very well. It's personalized to their care, and we make sure that the proper follow up and everything is sort of set up before they even leave the office.

00:14:58:16 - 00:15:09:12
Eric Boose, M.D.
So I feel like there's a lot of those tasks that I think that as the AI products get better and they do a little more deep dive into the charts and help us with all that context is where I see this going next.

00:15:09:15 - 00:15:32:06
Chris DeRienzo, M.D.
Well, if that is where we are going, then to all of the young folks out there who are studying medicine and nursing and respiratory therapy at an APP school, the future that awaits you is much better than the present that the folks on this call have lived through. We've gone through the challenging ages of early stage implementation and hopefully through the work that you all are doing leading the way at Cleveland Clinic,

00:15:32:08 - 00:15:43:08
Chris DeRienzo, M.D.
we will help bring some humanity back into the practice of medicine for all those who get to follow us. It has been a real privilege to get to speak with both of you. Thank you so much for joining us today.

00:15:43:10 - 00:15:44:17
Eric Boose, M.D.
Thank you for having us.

00:15:44:20 - 00:15:46:22
Rohit Chandra, Ph.D.
Thanks, Chris.

00:15:46:24 - 00:15:55:06
Tom Haederle
Thanks for listening to Advancing Health. Please subscribe and rate us five stars on Apple Podcasts, Spotify or wherever you get your podcasts.