Editor's note: This article was updated on May 20, 2021.
The Covid-19 epidemic has led to a rapid expansion in the digital health space, but how many of those innovations will stick around after the epidemic is over? In this episode of Radio Advisory, Warner Thomas, president and CEO of Ochsner Health, speaks with host Rachel Woods about the future of digital health and how Ochsner has been investing in the space.
Read a lightly edited version of the interview below or download the episode to hear the conversation.
Rachel Woods: The rest of the world really in the last year had to adapt to virtual care. And if I'm honest, that was largely in response to the Covid-19 crisis. But your organization is different, right? Ochsner was investing in digital solutions long before the pandemic. When would you say that digital health journey actually began?
Warner Thomas: So it's interesting, it's probably been going on for more than two decades. We actually built our own electronic medical record (EMR) back in the late 1990s or early 2000s, called the Ochsner Clinical Workstation, and it was built internally, we used it in the clinic. And it was pretty effective quite frankly; we had major adoption of that EMR right after Katrina, because we had to use EMRs in that environment.
Woods: Well, take me through a little bit of the timeline. If that was the initial spark 20 years ago, what have been some of the major milestones in digital transformation across the last two decades?
Thomas: Sure. So it was interesting, after Hurricane Katrina, we lost a lot of our medical records staff, and so the adoption of our EMR was exponential right after Katrina; we moved very quickly to that Ochsner Clinical Workstation. And then as we went into the late 2008, or 2009 into 2010, we realized we were not a great software company, and we needed to move to a new system. And that's when we chose to create a partnership with Epic, or we converted to Epic, in 2012.
Since then, we've continued to advance our Epic platform, built a lot of digital capabilities around the Epic platform, and stood up telemedicine in a much bigger way, four or five years ago. So it's been certainly an evolution over those two decades.
Woods: And like I said, this is very different than the typical health system. What was the initial spark? What early signs were you and your team tracking that said the future of health care is digital?
Thomas: I think our physicians have always been leaders and innovators. And we're always challenging ourselves to come up with better ways, and work together to come up with better ways, to take care of patients. And we knew the access to information was critical. It really is always been spawned by our physician leaders and their willingness to find a better way to take care of patients.
Woods: Have you personally been an advocate for this kind of transformation? Where does that come from?
Thomas: I absolutely have been, and I've always tried to compare health care with other industries. I remember talking more than a decade ago with folks about how it's amazing that we can book an airline ticket online, we don't have to go to the counter anymore to check our bags and to get our tickets, all of that is done electronically. And that has obviously evolved in the last decade. But it was amazing how health care was so far behind banking and airlines and other areas. So I've constantly tried to bring those other things about other industries to health care into our team.
Woods: Oh, yeah. I will admit to you that I remember the very first year that I joined Advisory Board, this was 2014, we did a research study and there was a case study in that research from Ochsner about the O Bar, which was modeled off of and inspired by Apple's Genius Bar, so exactly what you're talking about.
Thomas: Exactly, looking at other instances. And the O Bar was really created by one of our physicians, Rich Milani, our chief clinical transformation officer who knew that we were going to have many medical applications, there was going to be apps that people want to use for different types of issues to take care of their health.
And the question is, which one do you choose? So they have gone through that point in time, they'd analyze the apps and recreated the O Bar where you could actually go to the O Bar, we'd help you get the app installed, help you figure out how to use it. And it was a continued evolution of how we connected with our patients digitally.
Woods: I do want to take a moment and get some definitions straight, because the virtual care space, the digital care space is huge. And if I think about telehealth, remote patient monitoring, kind of asynchronous connection, those all represent absolutely huge pieces of care delivery, how have the different types of digital solutions been prioritized as your strategy has evolved?
Thomas: So, I think we have evolved that over the past several years. First of all it was using our Ochsner clinical workstation and then Epic to really digitize our clinical data, and how do we get it in a digital format? And to me, digitizing our clinical information is about 10%, maybe 15% of the value. The real value is how we use that data to take better care of people. And I think that's been an evolution over the past several years.
So you have that component, you have virtual care, there's really telemedicine and how we connect with people in a virtual fashion. Now, I think you're moving to more monitoring, like you said, remote patient monitoring, Telestroke, which is another idea of virtual care. And we really have strategies along all of these lines about how we want to connect with our patients, how we want to do things differently and better.
The role of leadership in digital health innovation
Woods: This is all a lot, but I have to think that there was some prerequisites that needed to be put in place to succeed here, maybe not from two decades ago, but when you think about the kind of people, the stakeholders, the technology, what things did you need to have in place first to make these massive investments?
Thomas: I think the first thing is always about leadership. We've made a big investment in leadership, going back to when I joined Ochsner in 1998. And we've created a very defined way about how we develop leaders, how we review leaders, how we orient them and train them, quite frankly.
That leadership has been key in our digital transformation post our conversion to Epic, and getting all of our organization on the Epic platform. Really it was then how do we use this information in different way? How do we use AI and machine learning to take better care of people and to analyze our data very differently? How do we stand up and work on virtual care? It's more than a decade since we started Telestroke and built the largest telemedicine program across the entire Gulf South region, but it's always been about people and leaders.
Our stroke telemedicine program was started by a guy named Ken Gaines, who at that point was the chair of neurology, was his idea; he came to us and said, "Look, this is something we should be doing, how do we grow and develop this." So it's always been tied to key leaders in our organization who brought forth ideas, not just one person or one group that needed to own the strategy.
Woods: And that's more than just luck, right? You've mentioned two and there are probably several other key leaders that have helped shepherd this innovation along and come up with new ideas. But again, it's not just luck that would make that happen, there's got to be a culture of innovation or something like that. How do you allow leaders to come forth with these kinds of ideas and embrace them?
Thomas: So I would say number one, we have a very defined strategic planning process that we run by region, that we want run by key service line, and we listen in those sessions for new ideas for new ways to use technology.
So our Connected MOM technology, which allows us to connect with moms who are around their prenatal visits and how they can essentially be connected to us digitally, which has allowed us to actually reduce our number of prenatal visits because some of them become done in a digital fashion, that came from our OB department. And it was through their strategic planning, we say that's an interesting idea, get with our innovationOchsner team, get with our CIO, Laura Wilt and see where they can where you can go with that, see what you can create.
And so it's about saying yes. It's about allowing people to experiment, it's about betting on people with their ideas. And also saying, "Okay," if it doesn't work, we've had so many things that have not worked, and we've moved on from them. But you have to be willing to bet on your people, listen to their ideas and let them make them a reality. And that is something everybody else looks at and wants to do the same thing.
Woods: And you mentioned innovationOchsner, which is the Innovation Lab founded by the health system from just I think a couple of years ago, is that really the thing that helps go from idea to actual tested and then implemented practice at the system?
Thomas: It is, it's one of the ways. We do give certain challenges and certain problems to our innovationOchsner group to drive and work on. But I would say the innovation happens every day, just in our IT department, in our clinical service lines, as they bring ideas forward to our data analytics group, which is part of our IT division.
We don't move everything to innovationOchsner, we put big problems there that we ask them to solve, and they're solving and working on remote monitoring right now. They created the O Bar, they created our digital medicine programs, really innovation is happening in a lot of different areas of our organization, not just one area.
Woods: And given that there's so much innovation, if I think about the virtual digital space alone, how do you actually create a process that allows you to prioritize and say these are the things that we want to invest in now, knowing that so many of your people are coming up with great ideas?
Thomas: That's always a challenge, right? There are always more good ideas than you have time and resources to put into them. So we do look at a prioritization process of what's going to help our patients the most, what is going to allow us to provide safer, higher quality health care, we look a lot at connectivity and ease of use, what's going to make it easier for patients to use Ochsner, and to have access to our facility.
So we really look at our process of prioritizing based on these components of safety, connectivity, quality, and also are there ways that we can leapfrog and just quantum leaps in how we advance care in many of our areas.
One example that I would give you is in our monitoring of patients for deterioration. And we've been able to reduce codes on our med surge units by 40%, because we monitor the data and we can actually predict codes before they happen. And we deploy a "Code Team or a Diagnosis Team" to look at a patient before they deteriorate, because we're able to look at their data and predict that. So that's one way of how we use it and frankly, which is just better care, it's safer care for our patients.
Integration vs. fragmentation
Woods: Given your long history of innovation, I have to believe that there are losses along with the wins, and that's where I think a lot of folks listening can actually learn the most, is from the mistakes, the barriers you ran into, and so on. Are there kind of problems that you or your team have run into that you'd like to help others avoid as they pursue their own digital transformation?
Thomas: Yeah, I think how you organize yourself is important. Now we set up innovationOchsner, I think it's been very successful. And they've done a great job. I think initially, we didn't build a lot of connectivity between our core operations and what innovationOchsner is doing.
And so that's been a little bit of a challenge for us, and we've continued to work on that even as of today, we work on that. I think being clear early on about what you really want to accomplish. I think innovationOchsner was really kind of a skunk works group that were just trying to take problems that they thought they needed to solve, and frankly, that's really important, and that group has been extremely innovative and done some amazing things.
Probably we could have done a better job earlier on kind of guiding and saying, look, we'd like you to focus on these three areas, or these five areas, and provide a little bit more guidance. I think today, it's interesting if you think about innovation and digital connectivity, it isn't comparing ourselves to other health systems, we have lots of different organizations out there, and it was something like $7 billion went into digital health in the first quarter of 2021.
I think the challenge now is that there are lots of folks trying to fragment the experience, they just want to kick off one little component that they work with patients on. We're trying to integrate the experience and have a more consolidated complete experience for patients and that's going to be interesting to see how that plays out over time, and see what patients really want? Do they want this fragmented one off experience that is really good in each area? Would they like a more integrated experience? And I think that's going to be the challenge that systems have to face and solve in the future.
Woods: Are you worried that the pandemic has almost made that tension between integration and fragmentation worse? I'm thinking specifically about how many Americans are getting their Covid-19 vaccines at CVS pharmacies, and if it's the CVS health hub, they can get access to health care right there. And it can kind of disrupt the primary care process, has that tension gotten worse since the onset of Covid-19?
Thomas: Yeah, I would say that CVS has its own view of the ecosystem that it's creating, and it wants people to be in its ecosystem that it's putting together of health hubs, of pharmacies, and what it provides from a preventive perspective, and I'm sure, building digital capabilities and home capabilities as well. So I think really, the situation that traditional health systems are in is that we're in a battle every single day for the relationship with our patients.
And our thesis here at Ochsner is that the winners long term will be organizations that have a strong physical footprint that's very distributed, very ambulatory, very convenient to use, coupled with a very strong digital footprint, with the digital capabilities and the digital connectivity for patients. And to be able to marry those and integrate those versus have them fragmented.
If you look at a CVS, it's got a very large physical platform, it's building the digital platform. The question is, what other services will it put in its physical platform, and will that be what wins the day for patients? Or will it be health systems and their large ambulatory platforms, and do they build the right digital connectivity?
I think those are questions that are really to be answered in the future, or is it going to be a number of small startups that performed their one little function extremely well and fragment the whole thing? And you're going to have eight different apps for eight different things on your phone. And , that's the way to go because you want the best of breed. We've really viewed that integration and connectivity and trying to make that experience between physical and digital very seamless, and very easy to use, will win the day, but once again, I think the jury's out.
Woods: Well, it's a good push to health systems because to act as a system, to get the benefits of scale, and to do so with a mix of in person and digital footprints, that's the only way you are going to compete in a landscape where the disruptors can't play, right?
Woods: They can't just overnight become an integrated delivery system. So rather than trying to win at their game, which is might be the best digital point solution, you've got to do something better. And that comes to exactly your point, integration.
Thomas: Exactly. I mean, for example, we've got a large ambulatory platform, but last year, almost one in four appointments at Ochsner were booked online with no interaction from human at Ochsner.
Woods: Was that right before the pandemic or in the middle of the pandemic?
Thomas: It was through the whole year.
So nearly one in four patients booked their appointments online themselves. Now, it's one thing to have the technology, but it's another thing to have your schedules configured and your physicians bought in to have schedules open so patients can book appropriately. And a lot of work has gone into building the right algorithms to match the right patient and the right patient condition with the right physician.
Because once again, if you've got back pain issue, and you just see a general orthopedist who doesn't do any sort of issues with back pain or you go into neurosurgery and that person does not have the expertise in back surgery, or wherever you enter the health care system, you don't want to get married up with the wrong provider. So it's not just about technology, it's about the change management that goes behind the scenes to make sure your schedules are open, your providers and physicians accept that type of change.
The pandemic as a catalyst for telehealth
Woods: Let's think about the world of telehealth specifically, it can be the whole world of telehealth, so this synchronous virtual visit, the asynchronous visit, remote patient monitoring, etc. What I found is that the workflow for the clinicians especially is key. Frankly, if I can be blunt, I often tell leaders, if the workflow is bad, this digital solution is not going to be adopted no matter how good it is for patients. Is that something that you found as well?
Thomas: Yeah, I think we would agree with that. I mean, I think if it's difficult to use for the physician, if it's not slick, if it doesn't integrate to the rest of their workflow on what they do, I think adoption is going to be very difficult. But the same as for the patient. I mean, if it's difficult for the patient to use, they're not going to use it either.
Woods: So then how do you make the workflow seamless? How do you make the digital path, the easy path for, let's start with physicians?
Thomas: It comes back to, obviously with an epidemic, there was a lot of tremendously bad things about the epidemic, and it was a terrible thing, and it's a terrible thing we've all gone through.
When it comes to virtual medicine, it was a very positive thing, because the adoption got quick overnight, literally, we did about 3,500 telemedicine direct to consumer, telemedicine visits in 2019. And in 2020, we did 330,000.
Almost 1,000% increase.
Woods: I should be clear that the numbers that you hit in 2019 are astronomical compared to average, that it wasn't uncommon for me to talk to organizations who would measure their virtual care volumes per month in the dozens in 2019.
Thomas: Right. And we push that hard. And that was half a year, we started that very robustly in July of 2019, we did a lot of direct connection to patients, about 3,500. So then in 2020, fast forward, I think 326,000, or almost 330,000, at one point, we're doing 15,000 virtual visits a week. So the adoption from patients, because they need to see their physicians and providers, the adoptions from our physicians was very well done, and the infrastructure and our ability to scale stood up very, very quickly.
So I think we worked through a lot of the workflows, because people had the time, because a lot of our clinics were shut down.
You couldn't bring folks in the clinic. So they had time to basically figure out the best way to do this, we continue to perfect that process. And then today, obviously, those numbers are lower, we're not doing 15,000 a week, we're doing about 5,000 a week.
But I do think that providers have figured out how to work it into their day to day work. We offer virtual visits on certain types of visits, we ask the person, do you want to come in person, or would you like a virtual visit? So we're giving the patient the option when they book the appointment, and I think that flexibility, that option, a lot of patients like it. Interesting enough, as our clinics open up, we really worried that folks will not be coming back to the clinic, I was surprised how many people wanted to come back to our physical locations versus stay with a virtual visit, I thought it would be a lot higher.
Woods: This is the question that I think leaders are grappling with right now, it's interesting that even an organization with a two-decade history in the digital space and in innovation still had this kind of, I'm going to call it boom and bust. Even if things didn't go back to pre-pandemic numbers, you still saw this dramatic increase in virtual visits that happened as a result of the early stay at home orders.
New Orleans was an early hotspot, makes sense for your organization specifically, but as numbers have come back down, frankly, as the desire among patients and physicians to resume "normalcy" has gotten bigger. There's this question of how much or what kinds of digital services need to remain virtual in the future? How do you answer that question?
Thomas: I think it's an evolution. I don't think anybody today has the answer on that.
Woods: Not even you?
Thomas: Yeah. I mean, I don't think anybody does, anybody says they know, actually I think they're probably mistaken. So I'm not sure where that ends up. And frankly, it's going to be a very individual thing. Take 10 people, you give them the same visit, I think you could get a very different answer. And I don't think it's based on age, I think it's really based on the individual and how they think about it and how they want to get health care.
So, obviously, we do see probably better adoption in younger populations. But I would say it's a mix across generations. So I don't know exactly how that plays out. I do know that we have to have the flexibility to do both really well. I do know that we have to have that experience to be able to integrate and keep our information in one place. And I do know that we need to provide the option and not argue with our patients and say, "Well, you have to do that virtually," or "Oh, you have to do that in person."
And obviously, there are some things you got to do in person because of how you take care of the patient. But I think providing options and flexibility is going to be important in how we meet the needs of our patients in the future.
Woods: I wonder as somebody who spent so much time in this space, if there are any myths or misconceptions out there that you just want to bust? You mentioned already the idea that older folks don't want to use digital solutions. Are there other myths out there that you just want to bust for our listeners?
Thomas: I think the idea of providing digital tools and just thinking people are going to use them is just not the case. I mean, just the fact that you offer something does not mean you're going to get major adoption of that. And you have to continue to make it available, help people understand the things they can do online.
As I said, we booked almost one in four appointments online, we did about, almost 2 million visits, essentially messages with our patients and our physicians and providers last year, we answered about 96%, 97% of those messages same day, which is what people expect. But once again, you can't force people and say, well, you have to message us or you must come in, you got to provide each of these options to folks and it's going to be up to the person to decide what works best for them.
Again, the challenge is that flexibility, that workflow is different by physician as well, because they can have patients that want to approach care in very different ways. So I think that makes practicing medicine today a lot harder for a lot of physicians. And I think we need to keep working every day to make it as easy for folks as possible, given the flexibility that we're trying to provide to our patients.
Looking to the future
Woods: What's next for Ochsner when it comes to innovation and virtual care specifically? Cast forward five years, where do you want to see Ochsner, and what's the path to getting there?
Thomas: It depends on exactly how we do remote monitoring in the home, how we own those connections in the home is really important. Organizations like Buoy that have done essentially kind of symptom types of programs that you can kind of self-diagnose with AI, I think is a really important component, but once again, it's a great service, it's got to be integrated to the rest of what you do. It's great if you have somebody kind of decide what's wrong with them, and then the question, and then what? And then where do they go? Do they go to urgent care? Do they need to go to the ED? Is it just a primary care visit? Do they need to see a specialist?
So I think those solutions stand alone, if they're not integrated are less helpful. But I think home and remote monitoring is a big, big focus for us going forward. I think how we use the digitized data that we have to predict. The way I like to describe this is, we needed to move from reactive, where people call us, or they show up at the ED, they go to our office, to being proactive, where we reach out, we tell people about the fact that they haven't had their preventive care done, we tell people that they need certain screenings done and then we move to predictive.
We predict that based upon the types of conditions you have, we would predict that you would be hypertensive in the future, we would predict that you would have diabetes in the future, we would predict that you will be readmitted to our hospital, so that we can intervene quicker and earlier and help people be more proactive in taking care of themselves. So that reactive, to proactive, to predictive is the way that we like to think about how we're approaching our solutions for our patients.
Woods: There's something that you did not say, and frankly, I'm not surprised that you didn't say it, but I want to point it out for our listeners. When you thought about the future of the digital space, you did not say, video visits. You did not say asynchronous video based appointment like the Zoom calls that we all have every day. And I think that's important because I certainly don't think that's where the future is, frankly, I think that's a little bit more of the past than people are willing to admit for themselves.
And if I think about where folks are investing right now, my push would be towards more of that store and forward messaging, towards more of that remote patient monitoring, towards what you said about using data even now, because that is really where we need to go in the future.
Thomas: Video visits, virtual visits, whatever nomenclature you use, I think is a piece of this solution. I think the question is really around, how do you win at patient engagement? Historically we've thought about patient satisfaction and whatnot, is, "Hey, what's your experience when you're in our ED, or when you're in our hospital, when you're in our clinics?" To me, that's when folks are in your four walls, that is not where we are today.
I mean, the question is, how do you engage patients when they're not within your four walls? How do you let them know that you're thinking about them, when they're not in your clinics? What is the way you're going to engage them to take better care of themselves, and how can you do it in a way that's not intrusive, but it's more coming alongside them and being a partner?
So I'll use an example—our digital medicine program for hypertension, people that have hypertension, it's out of control, and the control group, about one out of five people get their hypertension under control. These are people that start out of control, have high blood pressure. In our digital medicine program, we essentially send folks home with digital blood pressure cuff, it syncs to their smartphone which connects to our Epic platform. And we have pharmacists and health coaches that are constantly reaching out to people, we have technology at sending messages to folks to engage them to take their blood pressure, and remind them to take their medicine. If we see their blood pressure creeping up, we'll be in contact with them and intervene.
We see four out of five people, 80% of people keeping their blood pressure under control with our digital medicine program, of course is a control group of 20%. That's coming alongside someone and helping them manage their own condition in a very different way. And the historic way is we'd bring somebody in once a quarter to be seen. With our digital hypertension program, people are taking their blood pressure four to five times a week versus four times a year. Very different.
Woods: And this is so important because it speaks to the fact that data is out there, patients are generating more data than ever before, it is a question of how do you capture it, and how do you use it?
So I think about how many people have their own blood pressure cuffs at home. Now, they might not be digital blood pressure cuffs, but you can buy one on Amazon, you can buy one at your local grocery store. Let's instead get that in the hands of patients so that we can actually use that data and intervene. That's incredible.
Thomas: I think it's a big difference, right? I mean, it's one thing to take your blood pressure four or five times a week on your own, it's another thing that your health care providers looking at it, they're calling you up, they're titrating your medicine differently, they're talking to you and coaching you about diet, about activity, and about taking your medicine.
I mean, one of the things we've seen in our digital medicine program is, pharmacy costs go up, pharmacy costs go up because people are taking their medicine versus the control group, ED visits, hospitalizations, total medical costs go down. So I think intuitively it makes a lot of sense, right? But it is a very different model of how you try to take care of someone.
Woods: I get a little nervous that some folks might be listening to this and thinking, "Wow, they are so far ahead of where I am in my own digital transformation journey," do you have some key lessons learned or a message you want to share with the organizations and programs that are really at the beginning of their journey here?
Thomas: First of all is, no one has to recreate the wheel here, right? You can learn from other organizations like us or like others out there. I mean, we've learned from other organizations every single week, about what other people are doing. So nobody has the answer here. And we need to all be fast learners from other organizations that maybe are a little bit ahead of each other in different areas. So we constantly align.
I think the other thing is, you got to start, you've got to be willing to commit that, "Hey, I have to have a digital strategy. I have to figure out how I connect with our patients differently." And look, if you're a smaller organization, then maybe you should partner with an organization that's larger that may be able to help you with some of these tools. One of the things we've done at Ochsner is, we've got great partnerships with organizations like St. Tammany Parish Health System, Slidell Memorial Hospital, are two examples that we provide our IT platform to them and IT services to them. And we're able to bring some of these tools with that capability.
So you can do these things in partnership, you don't have to create it all yourself. But you do have to commit to a new way to think about the world and a new way to think about taking care of people. And we also have to understand that, nothing against my colleagues at CVS, or Amazon, or startup ABCD, out in Silicon Valley, they are all trying to get that patient relationship from us. And if we don't stay proactive, and keep bringing different solutions, we will lose in that battle.
Woods: Yeah, absolutely. I do have one final question for you, and it's the one that I asked on every episode. When it comes to innovation, when it comes to the digital space, what's the one thing you want our listeners to take away or act on right now?
Thomas: I think when it comes to digital is, as I said before, you have to start, you have to commit to want to do this, you have to commit to want to do some things differently. And you have to understand that this is where the world is going. All you have to do is look at anything else you do in your life, banking, how much you've bought online in the past year when you were at your home stuck in your basement, and you need to have stuff, I mean, you're buying it all online, right?
Well, that's how people want to access health care. And maybe not all of the delivery of services, but they want to be able to get this information and get to you in a digital fashion. And if they can't, they're going to find a way to do it, either with a your competitor, or with another organization that's more national. And I think that is the important thing for organizations, you got to start, you got to commit to this, and you got to keep learning every single day.