Rae Woods: From Advisory Board, we are bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae. I am hearing a ton of buzz about all things digital right now. And given the pace of investment and innovation over the last few years, I'm not surprised. It seems like every organization wants a piece of the digital pie. But today I want to pause and look closely at the actual meaning and goals behind digital health. And of course, how to make those goals a reality. To do that, I've brought our resident digital health expert John League. Hey John, welcome to Radio Advisory. John League: Hi Rae. It's great to be here. Rae Woods: So you are the tech guy at Advisory Board. Are you a tech guy at home? Are you one of those people who needs to have the latest gadget, wants to be connected? Are you that person? John League: Oh God, no. Rae Woods: No? John League: No. We finally cut the cord on cable and phone here and went to Hulu just a few weeks ago. Rae Woods: Good for you. John League: We are not on the bleeding edge probably in any way. Rae Woods: Only in research. John League: Right. Exactly. Only in the cutting edge perspective that we bring to you, the listener. Rae Woods: So John, we know we've been tracking this increase in interest in digital health before the pandemic, but obviously we've seen that interest skyrocket over the last two years. You talk to executives about this every day. What do they say when they talk about digital transformation? John League: Well, to be honest, they're all over the place. Really. They can think about this in terms of how does digital transformation inform the changing landscape in healthcare? And all of that is true. That is a thing. Right? Rae Woods: Yeah. John League: Of course, we know that. But I think it is entirely possible to miss the trees for the forest in that regard. We just assume this is this big trend that is going to carry us away to another place. And we don't really get into the specifics of the implementation, or how that matters, or unintended consequences. Rae Woods: Do you think that the market is all over the place in the kinds of digital innovation they're pursuing? I used to call this shiny object syndrome. "Oh, there's this cool thing over here that I've heard about." "Oh, this other organization has created this new innovation that I'm interested in." Or are you hearing just fundamentally different business goals from folks? John League: Oh, yeah. I get a different definition of what digital transformation is almost all the time in terms of where a specific organization is focusing. Sometimes you hear it in terms of, we need to digitally transform the clinical enterprise. And there's a lot of value there. We need to bring technology into the clinical space. We need to reduce documentation demands. We need to help people practice at top of license. John League: There are all of those things that are genuine concerns and have real value and there's a lot of leverage there. However, using that same digital transformation term, I also hear people talk about consumer experience and how do we orient more towards expectations? How do we act more like Amazon? How do we get a better consumer and patient intelligence, about how to reach out and how to connect with people? And it varies from organization to organization. I would also suggest that it is probably varied within organizations about how they're defining all of these different digital possibilities. Rae Woods: So if the market doesn't have a clear goal for their technological efforts, as well intentioned as they might be, what is the end goal? What does digital transformation look like? John League: We think it's five things. And if you remember only one thing about this from the podcast, remember that digitally enabled care is end-to-end, it's omnichannel, it uses technology and data, and it is both proactive and holistic. Rae Woods: Okay, well, we clearly need to dive into each of these elements. What does end-to-end mean? John League: It means that we have to think about the entirety of a patient consumer member journey when they interact with healthcare. That means longitudinally, so how does this person interact and receive care across their entire relationship with an organization? But at the same time, it also means what are all of the upstream and downstream pieces of a single encounter that go beyond what happens when they're in front of a clinician or in a facility? Rae Woods: So it's not just digitizing a single point solution, but thinking of about the whole experience, maybe even the experience when someone's not a patient. Like when they're searching for care, or when they've left the four walls of a healthcare organization and need to... I don't know, pay their bill. John League: Absolutely. It means all of those things. Certainly, like, Rae, if I know that you always pay your bill when I send you an email, why am I going to waste everybody's time by sending bill in the mail? Having that kind of information about you and an understanding of your preferences matters. It matters a lot. And we have historically in healthcare only focused on either the clinical interaction or from the plan perspective, the financial interaction. And it's all of a piece, it's scheduling, it's billing, it's follow up, it's pharmacy, it's navigation. All of those things matter. And in as much as those seem like they are beyond the scope of the healthcare enterprise, we're going to have to start thinking about that more as big retail starts to come to bear on all of these things and the influence that they have over how consumers perceive their healthcare options. Rae Woods: So step one is to think about digital transformation as being end-to-end. It's the higher experience. But the second word you said to me was omnichannel. What does that mean? John League: Well, first of all, I kind of hate this word because we hear it thrown around a lot. Right? Rae Woods: There's a lot of buzz words in this conversation, which is why we're going to be going into each one in detail. John League: Exactly. And apologies for the buzz wordiness. And I'm going to use another one to sort of give an example of this. So with omnichannel, like you've heard of digital front door. Right? Rae Woods: Yes. Oh, yes. John League: Yeah. So we've always known that the digital front door isn't really what we're talking about because most healthcare organization's digital front door is actually Google. Rae Woods: Yeah. John League: That's where everyone finds out about what healthcare services or available to them. But Google doesn't necessarily deliver people looking for your services where you expect them to show up first, whether that's on your website or to which page they go to. So people talk about things like I've heard the digital front porch, I've heard the digital back door. The point there is trying to be more inclusive. That where they want to be. That said, omnichannel can't just be about having a digital way to access individual healthcare services. It's about people looking for care, being able to find that care no matter how they connect. And that one experience is unified. So all of the channels lead to the same place. John League: If I switch from one channel to the other, the same information is available both to me and to the organization. The worst thing is when we try to have patients, members self-serve. And tell me if you've ever experienced this Rae. You try to self-serve, you can't really get the answer that you want online. So what do you do? You call the number. Rae Woods: Mm-hmm (affirmative). John League: You call the number, the person answers the phone. You tell them what you're trying to do. And far too often their answer is like, "Oh, well, I can't see what you are seeing." Rae Woods: Yeah. John League: Because, reasons. There's some reason that the information that flows to you does not flow to this person on the phone which is enormously frustrating and not the way that other industries have built their digital capabilities. Rae Woods: And to be clear, when we're talking about omnichannel, one of the most important things you said is that all roads kind of lead back to each other. We're not just adding and slapping an additional channel on top of things. I will tell you from personal experience, this week I took my son to the pediatrician and we went to check in and they said, "Did you get a text message to check in for this appointment?" And we said, "No, we did not." And they said, "Okay, we want you to download our new app that you need to add to your phone, to do the whole check-in experience, et cetera, completely separate from any of the other apps that we have, by the way, for our healthcare." And my husband and I both looked at each other and we went, "Another thing? Seriously? This is making it harder, not easier. This is adding more friction to our healthcare experience. Not less." John League: I think one of the interesting things about sort of the proliferation and the funding available to all of the new kinds of digital health applications, technologies, whatever you want out there. One of the perverse things, if you will, about it is how much of that is directed at lowering all already relatively minor barriers to care that people with insurance and access to care already have. And that does a couple of things. One is that it ignores the people who are already underserved or ignored by the healthcare system, at the same time as it fragments care even more for people who already have access, it is the worst of both worlds. Rae Woods: So we've got end-to-end and we've got omnichannel. When you listed off your five things, you've mentioned two together. You said technology and data. Why do those things need to be connected? John League: Think there are two reasons for that, Rae. One is simply to frame the issue in the right way, to have the right mindset. It's very easy, as you said, to be distracted by the shiny new app gadget platform, whatever. Rae Woods: Pediatric app. John League: Pediatric app, new thing to download every time you go to a different place. Your plan wants you to have one. Your provider wants you to have theirs. They want you to have the EMR app. They apparently want you to have the check-in app on your phone. And then you've got whatever else you have that monitors whatever is going on with you. If you have a chronic condition, you've probably got some sort of management there. You've probably got some health and wellness app that you probably look at more or less regularly either because you're really into it or because you feel guilt. It's just all fragmented. And it's very easy to be distracted by that. What we really need to focus on is how does this technology serve up data more effectively to the person who needs that? Whether it is the patient, the clinician, the scheduler, the care manager, whoever, that is the thing we need to focus on rather than just getting the newest, shiniest, slickest thing out there. Rae Woods: So technology and data need to live together because technology is the thing, it's the platform, it's the watch, it's the app. But we need to make sure that we're not just these devices in silos, and we're actually using the data that comes from it. And that's why they have to live together. John League: Absolutely, because we can't tie together those two things unless we have the technology and the data. It can't be end-to-end. It can't be omnichannel if we don't have the data flowing across all of those things. What I can already tell you, Rae, is that people listening to this are going, "John, that all sounds great, but how do we do that? How do we achieve that? That's so hard for us." And I get that. That is part of the reason why the definitions that we talked about earlier are so all over the place. Rae Woods: Mm-hmm (affirmative). John League: The biggest challenge is not really plugging the technology pieces together. I think it is having a genuinely patient centered mindset, as we think about what we're trying to do to digitally. Because at the center of all, this is still the patient. No matter what other elements are involved, they have to be focused on the patient. Everyone agrees with that. But our incentives are not aligned to make that the case. Rae Woods: And to be patient centric we have to use digital transformation to be proactive and to be holistic, which are your last two points. John League: Exactly. And I think these are the things where all of the investments that you make in gaining that end-to-end view, in creating that omnichannel, openness to patients and clinicians, in marrying the technology and the data, this is where it pays off, because proactive is just not how our health system is structured today. It's designed to be reactive. It responds to emergent needs. That's not how we want to manage our most chronic, complex patients. And that's not what will keep our rising risk patients from becoming chronic, complex patients. It's where the push towards valued based care leads. So this is a capability that we absolutely have to develop. We have to be able to use these tools to identify the interventions that we need before conditions deteriorate. Rae Woods: So if you're listening right now, I want you to forget your previous definition of digital transformation and know this, digitally enabled healthcare is an end-to-end omnichannel experience of healthcare that depends on digital resources of both technology and data to facilitate proactive and holistic interventions at scale. John, that is a very lofty goal. Is anyone actually hitting that today? John League: Across all five of those dimensions, there are various component parts, admittedly, probably not. There are lots of organizations that have aspirations for this. I do think there are some orgs that get big pieces of this largely right. Rae Woods: Okay. Like who? Or like what? John League: If you think of orgs that have a well established health plan, they have a head start and I know every everybody else in provider land just grown because that's kind of cheating. I totally understand, I am sympathetic to that. But certainly Kaiser comes to mind. They've always been very proactive in this regard, especially in California. Intermountain is another one that works in that same sort of space. I think we're also seeing newer models of care businesses, if you want to use that term. I'm thinking like ChenMed, Oak Street, Cityblock. They're all trying to tackle this in different ways, but they start with the idea that they have to provide holistic and proactive care. Rae Woods: Mm-hmm (affirmative). John League: So they deploy or they build the tools they need to do that digital or otherwise, to make that happen. I think that is an interesting example for how this gets built out. Rae Woods: What about some of the other true kind of new market entrance? I think a lot of the growth, or at least a lot of the hype that we've seen in digital capabilities is coming from true new players here, even newer than the ChenMeds and the Oak Streets that you just mentioned. How are they approaching digital health transformation? John League: I think that's right to talk about the new players, but the thing to remember, even as we see all of the exciting, flashy tech, when you see what happens at [inaudible], that's really not what's happening for most of the healthcare players and certainly for most patients. Most traditional players are thinking about out how to move forward, but they're not on the bleeding edge, like many of the organizations who get all of the attention because of VC and PE investment and all of those things. Most patients are continuing to get their care from these legacy organizations. And those legacy organizations are still largely in the early stages of what they're doing. Remember, we are still working in a world dominated by EHRs, which are not the most intuitive or friendly of environments. That's not a dig at those folks. That's just not what they were designed to be. Rae Woods: No, they weren't designed to do true digital transformation. They were designed to digitize billing. John League: Exactly. Exactly. And many organizations have relied on their EHR provider to pace them in their digital transformation. We hear a lot of people who say, "Epic is the single biggest investment we've ever made in our organization. We're going to go to the end of the road with them." Rae Woods: Yeah. John League: So they are content to wait until epic has evolved whatever sort of bolt on, or add on, or new capability that they have. I'm just not sure that that is going to evolve fast enough relative to the way that both consumers and payers are going to want digital experience to transform in healthcare. Rae Woods: So if the new market entrants are coming up with these flashy kind of solution, that might work, but are still fairly niche, there are new kinds of provider organizations that have popped up over the last several years, maybe even 10 years, that again, serve a niche set of patients that are doing a little bit more. And then there's the incumbents that are very, very slowly making changes. I guess my question is, if no one has really succeeded here in digital transformation, how do you know that those five things you mentioned are the right answer? How do we know that's right? John League: I have a very personal answer to this, Rae. I could give you a lot of the information that we've gleaned over the past two years. And a lot of the conversations that I have, even with chief executives now who are really on board with thinking through how to make this real. But for me, I know this is right answer because I learned it from my 72 year old father. Rae Woods: Oh, wow. What do you mean by that? John League: Dad had TAVR at the end of last year. So minimally invasive valve replacement for his heart. He's fine. He did great. Rae Woods: Good. John League: Dad relied on one resource across the entirety of his TAVR journey that really surprised me in its effectiveness and how it helped engage him. And that was epic MyChart. Now that shocked me that he relied on it so thoroughly, and that's not intended as a dig at epic. That is just intended as a recognition of what the patient portal usually is. In dad's case, everything he needed to see was there. He relied on it as a single source of truth for all of the information he would need. It had all of the records from his local cardiologist. It had all of the records from his surgeon. It had all of the results of his tests. And there are a battery of tests that you have to go through with TAVR, largely to make sure that you're healthy enough to survive the procedure, certainly given his age and the nature of the treatment. John League: He also had a whole bunch of COVID tests and stuff like that. But he could go there and see everything all at once. See what was coming up, see the schedulings, the appointments, all of those things. And he really relied on that. Having that unified view, that holistic view that allowed him to be proactive in what he was going to do and how he was going to prepare was enormously valuable to him. And he was extremely calm about the entire experience. John League: I was not. I was freaking out, "Oh my God, they're going to do something to my dad. They're going to climb into his heart and replace this valve." He was totally calm, and I think that was because he had the everyday assurance of every single time there was something to do or there was a new result, there was a place where he could look at it. Rae Woods: But this is not a common experience for a patient with healthcare technology today. In fact, I might guess that if your dad had a different encounter at the healthcare system, say, he develops type 2 diabetes and needs to have ongoing care for, for something like that, or some other episode comes up, I would [inaudible] to believe that he's not necessarily going to have the same experience as he did with his valve replacement. John League: Oh, absolutely not. TAVR's a bundle. Right? So that's not actually like what we think of as value based care. It's the same sort of idea. Like the hospital is getting paid for the whole thing. So not only are they incentivized to make sure that all of those pieces go well, but it's much easier for them to capture all of that information in one place because it matters to them. Rae Woods: That's right. The incentives lined up for this particular healthcare encounter and it does not do that very often in healthcare. John League: No, exactly. And let's be honest here, Rae. My dad is 72, he's on Medicare, but he is a white, affluent, cisgender male. He has always had healthcare. He always has had employment. He has always had a social network. He has always had access to food. All of those social determinants of health, dad is totally safe on all of the things that could lead to poorer outcomes. He is a model TAVR patient potentially. And that is not the case for most of the patients that we were talking about, that we're talking about in terms of like how we use this to help our chronic complex patients or our rising risk patients. He's not where the leverage is in bringing down the costs of care and improving experience for everyone. Rae Woods: But let me ask maybe a blunt question when it comes to all of these entrants that we're seeing focus on the digital landscape, focus on making point solutions better, focused on creating more connective tissue between different points in the healthcare system, don't you think their target end user is people like your dad or maybe people like you and me? John League: Oh, sure. The vast majority of players, startups, incumbent, whatever, they are focused on products for patients who are willing to pay. They are not necessarily designing them for patients with the most need in mind. We certainly see that around behavioral health, for example. Rae Woods: Yeah. John League: And I think that that is just coming more and more true as we see increasing investment and the sort of divergence of platforms and funding opportunities that are happening out there. I think most of the progress in digital health that exists so far has mainly served these kinds of patients, which is not to say that there are not people out there trying to extend care to folks. I don't mean to say that all digital health, I don't want to paint with too broad a brush. But let's be honest, who we're trying to serve and what investors in digital health largely expect is to have a viable market into which they can sell, and that largely addresses the commercially insured population, the Medicare population right now. Rae Woods: Our colleague Ty Aderhold came on Radio Advisory a couple of months ago and shared just how important it is to embed equity into the entire life cycle of digital products, from the moment and idea is kind of sparked in someone's mind to when it's actually implemented and when it's actually interfacing with patients and caregivers and consumers. Now, like I said, that was a few months ago. What have we learned about digital inequities since then? John League: Well, Ty made the point then that digital access is a social determinant of health. And we have to start thinking about it that way. That's absolutely right. And now actually we have some data to back that up. There was a recent study published in JAMA that suggests that a lack of internet access was associated with higher COVID-19 mortality rates. And that does control for levels of wealth and things like that you might expect this to be a proxy for. What's interesting is that the lack of internet access was correlated with higher mortality in both urban and rural settings to the same degree. Rae Woods: Wow. In urban settings, I would not have expected that. John League: I think we tend to underestimate how little broadband access, for example, there is in a lot of densely urban settings. I think the study tells us that internet accessibility is not just a rural issue. Digital inequity is impacting health across all of these dimensions. So it's not just an access problem. It's not just, is there a broadband cable near my house? I think it's far more than that. But when you think about it, it makes intuitive sense. Without internet you can't get telehealth. We can't forget that the internet is a main source of information. Rae Woods: That's right. John League: Without the internet, people live in digital information deserts. And as much as a food desert, I think that can have an enormous impact on their health, especially with something like COVID, that changes so rapidly in terms of our understanding over time. Rae Woods: So how can all of the people listening to this podcast, how can the providers, the startups, the tech companies, the fund make progress on digital transformation while also working to reduce inequities like these? John League: One problem that digital progress in healthcare, if you will, can actually solve, I think is this issue of scale. We can't solve equity problems and attend to other healthcare goals at the same time manually. The problems that we are experiencing in healthcare require new solutions. We simply can't just throw more people at them, assuming that we could even find the people to throw at them in the first place- Rae Woods: That's right. John League: ... in the markets where we need them. That's just not a reality. We have to start opening the door to using these new tools, to get to scale. Rae Woods: While John, when it comes to digital transformation, what is the one takeaway or the one thing that you want our listeners to do as a result of listening to this conversation? John League: I actually want them to do two things, and I know that's cheating, but they are related to each other. So I hope you'll allow it. I want them to be specific. Stop speaking in buzzwords and stop using the term digital transformation to mean 10 different things or nothing. Rae Woods: Yeah. John League: The other thing I want them to do is I want them to hold me to that. I have used the term digital transformation. I couldn't even begin to count how many times I've used the word digital transformation, how many times I've put digital transformation on the front slide in the slide deck. Help us to be true to this focus on what we're trying to achieve when we think about digitally enabled healthcare. Rae Woods: Nailed it. Couldn't have said it better myself. Thanks, John. John League: Thank you. This was cool. Rae Woods: If I'm honest, when I see headlines about digital health, I see a lot of folks that simply reference the massive amount of investment and they call that a win. But that's not actually the whole story. We cannot stop at investment. We need to move towards true digital transformation and we need to make sure our digital progress works for everyone, especially the people who need it the most. And remember, as always, We are here to help.