Eve Cunningham 00:00:00 We are going to have a very severe access challenge that's going to continue to become worse if we don't address the need for clinically appropriate access to care.

Keith Reynolds 00:00:18 Welcome to Off the Chart with Medical Economics, a podcast featuring lively and informative conversations with health care experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. I'm your host, Keith Reynolds, and today we feature a conversation between medical economics editorial director Chris Zeleny and Doctor Evie Cunningham, chief of virtual health and digital care at Providence, founder of med Pearl and an ob gyn. Today, they'll be talking about challenges with patient management and workflow.

Chris Mazzolini 00:00:50 Doctor Eve Cunningham, thanks so much for joining me today. I really appreciate it.

Eve Cunningham 00:00:55 Thanks for having me. Excited to be here.

Chris Mazzolini 00:00:57 So today we're going to be chatting about some of the common, you know, patient management and workflow challenges that doctors deal with. And in some ways that Doctor Cunningham and her team is working to address them. So the first question I have for you is, you know, around, you know, sort of thorny areas like evaluation and management, referral decisions, you know, why are these things so challenging and time consuming for primary care physicians?

Eve Cunningham 00:01:23 Yeah, I mean, the world today is very different from the world.

Eve Cunningham 00:01:27 When I went to medical school, and medical knowledge doubles every three months. When I went to medical school, it was every 20 years. And medical knowledge does not live in the electronic health record. the electronic health record isn't clinically intelligent. Okay. And then the average patient chart has anywhere from 50,000 to 200,000 data points. So it's it's almost impossible for clinicians. I mean, it is it's impossible for us to consume all the information that we need to know, and all the information that's in a patient's chart to really inform the best decision making. So this feeling of overwhelm, it's more severe and more significant with primary care. And the reason why is because me, I'm an ob gyn physician. When I go into a patient's chart, I only have to look up the things that are relevant to the gynecology patient that's in front of me. So if they had a knee surgery last year, you know, that's interesting, but it's not something that I'm typically going to do very much with from a clinical perspective.

Eve Cunningham 00:02:31 So the chart biopsy that I perform is much narrower than somebody like Primary Care who they feel, responsible for all of it. And when we talk about the referral dysfunction, the issue that we have here is that it's estimated that about 50% of the time when a patient gets referred from primary care to specialty care. There's probably some opportunities to improve or optimize that transition. And it's usually clinically related things. So for example patient gets sent to the wrong specialist. This just happened to me a couple weeks ago where I saw a patient who got referred to me. I'd waited four months to see me, and she really needed to see endocrine because she had an endocrinology problem. So for me, I said, I can't fix your problem, you have to go to endocrine another three months to see that. That happens all the time. You talk to doctors, they say, oh yeah, that happens all the time. The other thing that happens, patient gets referred to the headache specialist. Let's give an example.

Eve Cunningham 00:03:41 because they have chronic headaches and it's sort of you know, the primary care sees a lot of patients with these headaches. They're really complex, you know, to kind of distill down to what to do and optimize the plan and the patient waits for five months, which is the wait time that we have here to be seen. And the primary care clinician could have done 2 or 3 things medication wise, been empowered to do that and maybe ordered a imaging study if it was appropriate on the way to see the headache specialist. But they don't always have the right information in front of them at the point of care to to do that, because they can't consume everything, they can't know everything that they need to know. It's just not humanly possible. And that happens. That happened quite a bit, where the patients get sent to the specialist and they don't have an optimize, what we call workup, you know, multiple things that you could do on the way to see the specialist. And then the third thing that happens is there's a lot of patients we see that don't need to see the specialist at all.

Eve Cunningham 00:04:48 Right. And so the the problem that we have today now is that we have a shortage of doctors. We have 10,000 patients aging into Medicare every day, and we have a massive amount of burnout and a lot of primary care clinicians leaving just because it's just not sustainable. And so we are going to have a very severe access challenge that's going to continue to, to become worse if we don't address the need for clinically appropriate access to care. It's not just about access to care. It's about making sure the patients, the most clinically appropriate patients, get to the right type of clinician with the right pre pre visit workup and at the right level of urgency. And if you can solve that problem, think about how much access we can open up to care by making every visit count. So that's the problem that we're trying to solve with the solution that we're building.

Sydney Jennings 00:05:59 Say, Keith, this is all well and good, but what if someone is looking for more clinical information?

Keith Reynolds 00:06:04 Oh, then they want to check out our sister site, Patient Care Online.

Keith Reynolds 00:06:08 Com the leading clinical resource for primary care physicians. Again that's patient care online.com.

Chris Mazzolini 00:06:19 Med pearl is the solution that you guys are working on to try to address some of these obviously thorny issues that all doctors are dealing with. So can you talk a little bit about med Pearl. And you know how it came about, what it's aiming to address. And, you know, just sort of the story of that a bit.

Eve Cunningham 00:06:38 Yeah. So I was working as a chief medical officer of a medical group, and I was I've been a physician leader for years where I've led physician groups. And this problem with referrals was like something I would hear all the time. Primary care complains. They say I don't know what the specialists want me to do, or the specialist rejects my patient, or the patient gets frustrated because they can't get in in time, and then they leave the system to go to a more a place to get sooner. And I just I'm so frustrated. And then you talk to the specialists, and the specialists say primary care doesn't know how to send me the right patients.

Eve Cunningham 00:07:13 I get I'm a surgeon. Why are they sending me medical back pain, for example, when they should be going to Pete? And so when you talk to the specialists and you talk to the primary care, there's a knowledge sharing gap that we have across our community. It used to be we would go to the the doctor's lounge and we sit down and we'd, you know, chat with each other and talk about each other's patients and collaborate that way. That was like the old days. Now we live a lot in digital silos, and so we're not always accessible to each other. We're not always communicating with each other, and patients are more and more complex, and there are more and more administrative things to do. So what I thought was when I looked around, I would hear this from my peers, right? My colleagues and everybody kind of knew this problem existed. There wasn't really a great technology solution out there, and the way we were trying to solve it was like sticky notes and PDF files and SharePoint and, you know, little algorithm sheets and things like that.

Eve Cunningham 00:08:13 Like when you refer to endocrine for a thyroid nodule, do this, then do that. And like, so all this stuff is floating around and it's completely unsustainable for primary care. It's not their fault. That's the other thing I want to point out. Primary care clinicians are amazing and wonderful humans. And they just what were we got to create technology for them so that they feel supported. So what we did was we went to them, we went to primary care, we went to the clinicians and we got some engineers together and we said, you understand this problem? Tell us, how do you want this information delivered to you? Where how do you want it organized? What are the rocks that you have in your shoes? How should we design the solution around you? And that's really the genesis of how Med Pro was designed. It was designed in a very clinician centric way, and we designed this platform where we can create, collaborate, govern, maintain and develop digitally consumable clinical content that can be delivered to the point of care in a back end clinical intelligence hub, where all of the content and all of the information that we share with each other is done.

Eve Cunningham 00:09:31 It's built by clinicians, for clinicians in a no code environment. And that was one of the missing pieces, is that we were always, you know, we had these Visio charts or diagrams, and we would have to give them to somebody, and then an engineer would have to load it into something. And then when you had to make a change, it would take, you know, you didn't have the, ability or empowerment as clinicians to change things. So we have topics in our platform right now. You know, they are changing every week like Covid, you know. And so we have to we can't depend on manual, you know, making changes on something, but then goes into another system that then goes to this, that then gets changed. We need to be able to update things rapidly and be empowered to do that. So that's what we've done. And then the platform itself, it it delivers the information, in from within the electronic health record so the clinicians can launch, launch within the electronic health record.

Eve Cunningham 00:10:28 And then it's context aware to the patient that you're seeing. And it gives next best actions and guidance around oh, almost 900 referral guides and topics and algorithms. Constitutes about 95% of what a PCP or primary care clinician sees. And then it also sucks out. It digs out the relevant patient data in the context of the particular condition that you're looking at. So it reduces cognitive burden. It speeds up clinical decision making. It eases the way for patients. It improves patient experience because it's improving that transition experience. And we're sharing knowledge. We're democratizing that expertise in a more meaningful way across our community.

Chris Mazzolini 00:11:18 So med Pearl came to my attention because I saw a case study in, I think it was the August issue of New England Journal of Medicine catalyst. can you tell me a bit about that case study, what you looked at, what you found, your conclusions and that sort of thing?

Eve Cunningham 00:11:35 Yeah. I mean, it really tells the story of the the genesis of the product and, and, and the different, things that we went through.

Eve Cunningham 00:11:45 But, yeah, I mean, we were able we were one of the things that's, I think really tough with a lot of these digital health products is that they don't always have evidence based research or really good analytics or data or outcomes to really demonstrate, like what is the value that you're bringing by bringing this solution in. And so we wanted to take a very data driven approach to showing the impact that we were able to make. So we we scaled we started with a pilot in 2022 with 200 plus clinicians, and we were able to demonstrate with that clinician group, when they searched med Pearl, 20% of the time, they didn't need to refer the patient at all. About 72% of the time. It helped them remind them to do something in the workup, or order a lab or order a test, or start the patient on a medication then they would not otherwise have done, and 20% of the time they changed the specialty or the level of urgency. So that case that I was telling you about patient should have gone to endocrine.

Eve Cunningham 00:12:45 That would have been solved if that primary care clinician who referred that patient to me had actually had med parole at their fingertips, because it would have directed them to do a different path for the patient. And so those are really great metrics and signals for an initial pilot to show. Like if we're making this much of an impact, think about the impact that we're making on clinically appropriate access, optimizing patients. So then we scaled the product across Providence in 2023. We started the scaling process. And that that was great. We've we've now gotten to a place where we have, over 7000 clinician users. We have, we did the EMR integration piece, Last year in September. So it's been about a year on that journey. And that really even accelerated the adoption in the U.S. we've been able to demonstrate improve productivity for our super users. So clinicians who are using it are more productive, but we're not asking them to see more patients. So that really shows that we're we're elevating them to a higher level of licensure.

Eve Cunningham 00:13:58 We've been able to demonstrate improved referral value. That's actually something that's really important in a health system. You look at the the value of the referrals and say, are we like what is the downstream consequences of these? these referrals are these patients that are getting referred for back pain, converting to surgery, or are they going to eat and are the ones that are converting to surgery more appropriately, going to the spine surgeon versus the ones that aren't surgical going to the pit. You want to make sure you make those delineations. And so you want your specialist to be seeing the, the, the highest acuity things that they should be seeing. And you want your, your advanced practice or your allied health professionals to be seeing the things that are more appropriate for non-specialist care. And so that's kind of the holy grail. If you can, you can create a mechanism to be able to do that. And it's a very clinical problem. So that's that's some of the metrics. We've also been able to demonstrate improved EHR efficiency scores and reduced pajama time for our clinicians for after hours.

Eve Cunningham 00:15:10 so those are things that that dig into the burnout factor. And then we also did in our pilot, I forgot to mention this. We did a, a pre and post survey on our pilot participants to say, what is your level of competence and confidence with doing referrals, working at referrals, sending referrals to the right way. with med Pearl, premed Pearl and postman Pearl. And there's a statistically significant improvement in confidence level as well, which is important because again, it digs into that factor around, feeling empowered, upskilling or onboarding folks more quickly. We know there's going to be a lot of advanced practice clinicians going into primary care, supporting the primary care access issues. We need to make them feel empowered as much as possible. So this technology really takes those the the wisdom from the specialist brain and codifies it into this platform and delivers it to them in a useful and meaningful way.

Keith Reynolds 00:16:17 Oh, you say you're a practice leader or administrator. We've got just the our sister site Physicians Practice. Com your one stop shop for all the expert tips and tricks that will get your practice really humming.

Keith Reynolds 00:16:29 Again, that's physicians practice.com.

Chris Mazzolini 00:16:37 So, you know, you had mentioned earlier on that, you know, a lot of this was built with, you know, sort of a real world knowledge and experience of the providers, the physicians that are on the ground, you know. Why is it so important to have, you know, the actual clinicians be involved in, you know, making sure a solution, you know, actually works in the real world?

Eve Cunningham 00:17:02 Yeah, I think that's kind of where digital health missed out on the last decade, to be completely honest. I think a lot of things, a lot of money was spent on building a lot of things that didn't get adopted and didn't get used, and it was all well-intended. You know, there were a lot of people who wanted to see if they could help fix healthcare. They saw it as right for, for.

Keith Reynolds 00:17:24 A,

Eve Cunningham 00:17:24 Disruption. It's very difficult to disrupt healthcare, because of just. It's different. It's different from the movie business.

Eve Cunningham 00:17:35 You know, we're not blockbuster. We're much more complicated than that. And so there just are so many factors and intricacies involved in a lot of the controls still remains with the people who deliver the care themselves. just from a regulatory licensing perspective. so I really do think and when you look and see some of the, the technologies that are really starting to launch and get a lot of, interest and buzz, I really do see clinical integration with those technology teams. And that code development process is probably being one of the most critical factors of the success. You have to understand how the work is done. You have to understand the workflow, the change management process, the psychology. But I think one of the reasons we've been successful partially is just because I was a medical group leader. I had a lot of relationships, I had influence, I had a great network. So we were able to kind of get that process started and get buy in for it. And then once the clinicians buy into it, they sell it to each other.

Eve Cunningham 00:18:46 Right. so it's not hard. We're we're not even we get inbounds all the time from health systems wanting to get a demo. That New England Journal article, for example, a bunch of health systems reached out. They're interested because they understand the problem. The problem resonates with them, and they know there's not a lot of great solutions out there on the market that address it in this way. Or you have to do a very customized, high maintenance build internally in your system if you want to address something similar. And it's not really designed for that. So, so that's why I really do think clinicians, it's very important for clinicians to be involved in the evaluation and assessment of these different, products and solutions that are out there, especially if they're affecting clinical care directly. Yeah.

Chris Mazzolini 00:19:37 Last question. What's next for med Pearl?

Eve Cunningham 00:19:40 Well, we are working on implementations in a couple other health systems. So that's really exciting. We want to bring this supportive technology to the world. We want to share it with the world, because it has brought a lot of joy and delight to our clinicians at Providence.

Eve Cunningham 00:19:59 And that is an extension of Providence's mission is to to meet the needs, of all communities in especially poor and vulnerable communities. I would say one of the biggest, areas of opportunity that I think med Pearl has is Meeting patients in underserved areas, in rural areas, especially rural areas where you have clinicians who are out completely on their own, it's 4 to 5 hour drive sometimes for a patient to get in to see a specialist. How do you empower that physician assistant or, family medicine doc that's out in a more rural area to be able to to maximize what they can do for their patients. And so we are one of the health systems, we're launching in two of them. Excuse me. Our, rural health systems. And one is a tribal health authority as well. So it's, really exciting for me to see that we are going to democratize knowledge and bring it into all these different communities and continue to extend the mission of Providence through this great technology.

Chris Mazzolini 00:21:19 Doctor Evie Cunningham, thank you so much for joining me today and sharing your insights.

Chris Mazzolini 00:21:23 I really appreciate it.

Eve Cunningham 00:21:24 Yeah. Thank you.

Keith Reynolds 00:21:31 Again, that was medical economics editorial director Chris Maslin and Doctor Evie Cunningham, chief of virtual health and digital care at Providence, as well as the founder of med Pearl. My name is Keith Reynolds, and on behalf of the whole medical economics team, I'd like to thank you for listening and ask that you please subscribe to the show on Apple Podcasts and Spotify. Also, if you'd like to digest of the best stories Medical Economics publishes delivered straight to your email six days a week, subscribe to our newsletter and medical economics. Com Medical economics, patient Care Online and Physicians practice are all members of the MG Life Sciences family.

Keith Reynolds 00:22:04 Thank you. For.