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Becker’s Healthcare Podcast
Kenny Cole, MD, System Vice President of Clinical Improvement at Ochsner Health System
00:27:14
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- [00:01]
A
This is Laura Deardow with the Beckers Healthcare podcast. I'm thrilled today to be joined by Dr. Kenny Cole, system Vice President of Clinical Improvement and Medical Director of Digital Medicine at Ochsner Health. Dr. Cole, it's a pleasure to have you on the podcast today.
- [00:14]
B
Thank you. It's a pleasure to be here.
- [00:16]
A
Absolutely. Now, I'm excited for our conversation. I know we're going to be talking about digital medicine, primary care, and the future of how both are growing and becoming more and more interconnected as time goes on. But before we dive into that discussion, can you tell us just a little bit more about yourself and your background?
- [00:32]
B
Sure. I'm an internist and a primary care physician at heart. I have spent about the last decade of my career in various administrative roles really attempting to facilitate the same mission, which is the transformation of primary care. My title, system Vice President of Clinical Improvement indicates my philosophy, which is that I think that there's nothing in healthcare that can't be improved. And I'm a strong proponent the role of technology in being able to facilitate those improvements.
- [01:08]
A
I love that. I think that's an especially open and important mindset and really tactic to take into the future. Now, from your perspective as a practicing internal medicine physician, how would you describe the current state of primary care today?
- [01:25]
B
Mission impossible. I think that. And that's not just hyperbole. There was a study that was done back in 2022 which really just expanded on multiple other studies over the past 20 years. But this particular study in 2022 was done in Chicago. It was published in the American Journal of Internal Medicine and basically attempted to quantify the workday of a primary care physician. And so what it postulated was okay, like if a primary care physician managing a panel of about 2,500 patients actually attempted to execute all of the guideline recommended therapy, all of the evidence based recommendations as it relates to preventive health, as it relates to chronic conditions management, documentation and inbox management and then managing acute conditions. How many hours would it take that primary care physician to do all of that? And the answer came back right at 27 hours per day. And again, that's not even the first time that a study has demonstrated that. That just built on the earlier work of OSPE and Yarnow, which basically came up with similar almost impossible type workloads on primary care if they actually were able to do everything that they're supposed to do.
- [02:49]
A
Wow, that's incredible. I mean, to really think about how long it takes and what really goes into each primary care visit. And the patients that primary care physicians are taking on, it's mind boggling. So what are some of the pressures, clinical, operational and workforce related that you're seeing acutely right now for these primary care physicians and in the field in general?
- [03:12]
B
Yeah. So the way that health system financing works or healthcare financing works is procedural interventions, surgical interventions, imaging services have traditionally been rewarded with the highest level of compensation. Actually sitting and thinking and listening to patients. It is not as financially lucrative, shall we say, as more procedurally oriented care. And so the tendency has been that for primary care to generate levels of income for themselves as well as a financial contribution to whether it's a health system or to their practice or whatever it may be, they typically have to see 25, 30 people a day, which unfortunately just doesn't lend itself to being able to do all of the things that you need to do for a given panel. And so it does lead to high levels of burnout within the field of primary care, where I know personally, not only did I probably burn out myself, but I have also said that in the years that I was practicing full time, I know that I never left a workday and all the work was actually done. And I think the three words I said more than any other three words in all the years I practiced were, I'm so sorry. And that was because I'm so sorry I'm running late. I'm so sorry I couldn't see you the other day. I'm so sorry I haven't called you back with your lab results yet. You know, things like that.
- [04:49]
A
Got it. And that, you know, it's such a helpful picture to paint, especially when you think about all the responsibilities that you have to go through with the different patients. And then to understand, you know, how you're approaching these conversations and always feeling like you're behind is not great. And so to your point, it leads to a lot of burnout and lots of challenges in practicing medicine. And so I want to ask a little bit more about how you're defining, defining digital medicine in primary care and how that's becoming more of the conversation, more of the solution. When we talk about digital medicine in primary care, how do you define its role alongside that traditional physician patient relationship? Where does it fit and how is it working to solve some of the challenges that you have been discussing?
- [05:34]
B
Yeah. So when you think about all of the tasks that a primary care physician has to do, part of that is the task of solving problems and the application of knowledge to that problem solving process. And then you sort of Think about the evolution of knowledge. And when it comes to the management of chronic conditions, quite a bit of the knowledge has evolved to such an extent that the knowledge is, is nearly explicit. Not quite, but, but when I say explicit, I mean that when the knowledge of a given condition or area is so evolved and so complete that typically what you can do is you can protocolize that knowledge or capture it into an evidence based care pathway where the reliability of the outcome is more dependent on adherence to the evidence based pathway than it is on a given primary clinician's individual knowledge and skill, or more tacit knowledge application to complex unstructured problem solving. And so primary care physicians have to do both, right? They have to solve the complex problem of the patient that comes in with fever and rash after having traveled outside of the country, but they also have to apply evidence based pathways to the management of chronic conditions. And so then when you think about the best use of time for a physician who's worked so hard to build out tacit knowledge through repetition and learning and experience, it seems like that's where a primary care physician is going to be best suited, is to solve those types of unstructured problems. Whereas an evidence based care pathway, potentially a less knowledgeable clinician, less experienced clinician, less expensive clinician, can simply follow evidence based pathways in such a way where you're reliably following the evidence, applying that evidence to the management of conditions and then achieving a differentiated result, where you're delivering, you know, things like 90 plus percent rate of blood, you know, hypertension control, 90 plus percent rate of diabetes control, and then doing that at scale through technology, where clinicians are leveraging not only technology, but remote patient monitoring, where you're getting data on like the blood pressures, you're getting data on blood sugars, and those are then coming into the electronic medical record. And so you get voluminous amounts of data on which to be able to exact and effectuate clinical decision making. Whereas in a traditional primary care practice it might be a person coming in for their hypertension visit twice a year and you get two blood pressure readings during those visits. It's almost impossible to make really good decisions with limited data and limited interactions and so digitizing it so that you have much more frequent interactions, you're following the most up to date evidence and you're just getting lots more data to be able to make those decisions.
- [08:45]
A
That makes a lot of sense and seems like it can really unburden some of the things that are so challenging for primary care physicians, whether it's on the operational side or even to your point in being able to support them, their decision making and support the way they're working with patients. Now why are additional touch points between these office visits so important for managing, especially when you're looking at chronic conditions or some of the other things that patients are coming to you with. And how, how does this model make that possible?
- [09:17]
B
Yeah, because, you know, think like things happen all the time in terms of, in between visits, you know, that can result in alteration of the data. You know, like I, I, I, like I, I can recall a patient specifically, you know, who had, has diabetes and I had spent, you know, some time working with her to make sure we got her diabetes controlled and we did like. So her, you know, A1C looked perfect the last time I had seen her, but little did I know that, you know, Christmas time for her is a really difficult time. She had lost some family members around, you know, Christmas time previously and she had a, a predisposition towards dealing with stress through food. And so her eating patterns changed dramatically over the holidays and she really started snacking quite a bit more. Her blood sugar sort of skyrocketed. And you know, she came back to see me a few months after that and, and what she told me was that what really got her out of it was the digital medicine clinician who saw her blood sugars rising. I certainly didn't have access to those, you know, sugars like or nor would I in a standard primary care practice. But the digital medicine clinician was able to see that change, was able to reach out, was able to, you know, find out what was going on, was able to connect her with a health coach and other resources to kind of help her get through that time. And then by the time she came back to see me, her diabetes was once again perfectly controlled. And so we never missed a beat. And that's only possible by changing the dynamics of how care is delivered away from episodic, discrete visit based encounters to more of a longitudinal, continuous, connected relationship.
- [11:06]
A
That's an incredible story, but I can imagine very indicative of some of the things that you see every day with the patients you're working with and those who have embraced this digital medicine model. How does the digital medicine enable more team based approach to care from your perspective, what does that interplay between the different clinicians and professionals that work to actually help keep patients well?
- [11:27]
B
Yeah, so going back to that study that was published in 2022, I mentioned the 27 hour day. But another element of that same study was that if you began to deliver care differently. If you would deliver care through more of a team based approach, where what you then did was try to divide up all of those different tasks, like all the things that a primary care doctor would need to do. And then you began to reallocate some of those tasks to members of a team where the skill set required to execute upon the task was different, different than what the physician skill set was. And so that included things like cancer screening or vaccinations or education, but it also included things like chronic conditions management. And when you then broke all those tasks across a team, you could actually get the work day down to about nine hours per day, which is a much more reasonable workload. But again, that's only possible with the implementation of a team based approach to primary care. Now unfortunately, the payers have not come around and said, oh, okay, well then let's go ahead and change the whole reimbursement of primary care such that we'll just give money to all of the different tasks that need to be done by the different team members and we'll just pay primary care more money in order to make sure all this happens that hasn't happened. And so you then have to now figure out, how do I solve the problem of mission impossible for primary care while being limited by the prevailing finances mechanisms? And the answer is you begin to get really creative in how you deliver care. And so you bring in, you know, pharmacists and advanced practice providers into the model and then you, you allow them to have access to the data and the technology to then begin to digitize the management of chronic conditions. You try to seek, you know, innovative ways of paying for that. Right. Since the payers aren't doing it, you, you try to figure out how to maybe put a funding mechanism and t to then be able to deliver those services. And then of course, within value based contracts that does offer some degree of flexibility to be able to deliver care differently and embrace more of this team based model. But yeah, it's integrating clinical pharmacists, advanced practice providers, health coaches into the primary care model as members of the primary care team with a shared goal of improving outcomes and delivering better care to the patients they all want to serve.
- [14:14]
A
That's so critical to understand and helpful to see how that process works. And I love the idea of getting creative and using all the data, the technology and the tools available to tackle the chronic conditions that patients come to you with and looking at innovative ways to really solve some of these problems, not only from the clinical side, but also from the payment and value side as well. What role do pharmacists and health coaches play alongside the physician in this model? And how does the team based structure change the way that physicians spend their time day to day?
- [14:47]
B
So I think what it really does is allow the physician to, you know, focus more on the, that component of their panel that they otherwise might be focused focusing on managing things like blood pressure, diabetes, chronic kidney disease, you know, and so forth. And, and so there's a couple things. One, it, it sort of takes away that the, the gap. It studies have shown that it takes on average about 17 years, you know, from the publication of a study that it actually disseminates and across, you know, practice patterns, you know, all across a large cohort of physicians. And so you dramatically shrink the amount of time that it takes because what you're doing is you're having clinicians whose only role is to make sure that they are staying very up to date on the management of these conditions. You're revising your pathways and your protocols as soon as new guidelines get developed. So for example, the new lipid guidelines just got released within the last two weeks and we barely had to change our, our protocols because we were already so up to date, you know, on the science. And the clinicians certainly were already so up to date. And so, so now you've got clinicians reliably applying up to date evidence based science as a member of the care team can still have reciprocal interactions with the provider and a shared electronic medical record so that the primary care provider can see exactly what changes are being made and when they're being made and how it's, it's, you know, how it's unfolding. And then what it does is it gives the primary care physician more time back in their day to devote to some of the other things that have gone unaddressed. So for example, you know, things like advanced care planning, which, you know, studies will show, you know, is, is under delivered, you know, across large populations of just having that conversation about end of life values, goals and preferences. But who better to have that conversation than their trusted primary care physician? And so it's, it's just rethinking the management of a panel across all that voluminous amount of work that needs to be done and who is best suited to be able to execute upon that work which member of the team is best suited to accomplish those given tasks.
- [17:08]
A
That's helpful to understand. And certainly seeing how the different clinicians interplay with each other seems like a much better, more streamlined and Coordinated way to deliver care, especially at scale. Now I know I've talked a little bit about burnout is on the pressures on primary care physicians. So how are health systems under pressure to expand access to care while also tackling burnout, which is critical and probably the two biggest challenges for many healthcare organizations today. What does digital medicine do to help address both of those? And what are you seeing in terms of trends for digital and remote care?
- [17:46]
B
Yeah, so if we look at that 27 hour day, you can break it down into various blocks of time and about eight hours of that 27 hours is, would be the amount of time it would take to manage all of the chronic conditions for a panel of about 2,500 patients. And so to as much an extent as possible, pulling off, you know, some of that chronic conditions management, never undermining the importance of the primary care clinician patient relationship. That still very important. But instead of a primary care clinician having to see a person with diabetes, you know, two to four times a year, it may be seeing them once a year as the check in and to be able to do the diabetes foot exam and to preserve the relationship. But meanwhile the patient's diabetes is perfectly controlled and you know, all of the appropriate labs have been ordered and you know, so, so it basically facilitates the job of co managing a panel where the primary care clinician still has ultimate responsibility for the outcomes, but has assistance in generating those differentiated outcomes.
- [19:01]
A
That's helpful to know and makes a lot of sense. And speaking of clinical outcomes, what types of outcomes have you seen improved through digital medicine, particularly for chronic conditions?
- [19:15]
B
Yeah, so basically it's, you know, we believe in, within our own digital medicine programs, looking at sort of HEDIS metrics, hypertension control rates are typically right around 94%. 94% of all of our patients have their blood pressure controlled. About 91, 92% of our persons with diabetes have their diabetes controlled. But it's not only that like it's, it's controlling hypertension and diabetes with, with the most efficacious medicines that not only control the blood pressure and the diabetes, but that reduce heart attacks, reduce strokes, you know, that are, that are basically cardio protective and kidney protective. An example of that are just the use of a class of medicines known as the SGLT2 inhibitors, which are decent diabetes drugs, but are phenomenal drugs for chronic kidney disease. And so looking at that patient holistically across those chronic conditions and making sure that, you know, an SGLT2 is not only serving its role of controlling diabetes, but that, you Know, in patients who have, you know, protein loss in the urine, that, that, you know, they're on the max dose of the right type of medicine called an angiotensin receptor blocker to reduce that amount of protein. Also on the SGLT2 inhibitor, you know, what that does is that then, you know, basically slows the progression of chronic kidney disease because we believe that there is an end in sight to the days of diabetes or high blood pressure, even resulting in end stage kidney disease because of the types of medications that we have available. It's just really a matter of reliably delivering those medications to the right persons. And then the other things that we have seen in addition to our control rates are just that, you know, when patients are enrolled in the digital medicine programs, they have fewer admissions to the hospital, they have fewer emergency room visits. And that makes sense, right? Because if you are indeed reducing the amount of heart attacks and strokes and you know, the instances of acute kidney injury and all of these types of things, you're reducing avoidable utilization in a way that that's best for the patient and correlates with those better outcomes.
- [21:27]
A
That makes a ton of sense and I appreciate your analysis and examples there. Now, I know a lot of healthcare organizations and systems are moving towards more value based care, trying to figure out how they can inject value into the broader, you know, ways that they're thinking about care delivery. So how does this model support those types of organizations and that move into value based care?
- [21:52]
B
Yeah, so this is the transition that has to be made, right. And you know, I've heard it described before as, you know, someone standing, having, having, you know, two, a foot in one canoe and another foot in a different canoe and having to sort of balance, you know, because, you know, if you're just 100% in the fee for service, then you know, you're really going to miss out on sort of the transitioning that's taking place as, as we all feel the need to lower health care cost and improve the health of the population we serve. But if you, you put your, your feet, you know, all entirely in the value based canoe, you actually risk losing enough significant portions of revenue that were driven by things like people having bypass surgery or people getting coronary artery stents or hospitalizations for heart attacks and things like that, what it does is it begins to give you and the ability to deliver care differently in a way that you never get reimbursed for in a pure fee for service environment. But as you're improving these clinical outcomes and you're reducing the amounts of heart attacks, the amounts of strokes you may actually eat into your revenue of your bypass surgeries, but it's in a good way. It's because you're preventing people from needing bypass surgeries. And at least under value based financing, you're getting, you know, some of those dollars that flow back into the system. And so you're being rewarded for keeping people healthy and out of the hospital, rather than for just reacting to disease and poor clinical outcomes as they occur. I think that the need to embrace digital technology and transformations in care delivery is essential to help facilitate this journey towards value based care transformation and overall, hopefully making healthcare more affordable by making people healthier and yet preserving the economic viability of the systems that are able to participate.
- [24:03]
A
That's helpful to understand and you know, it is really an amazing kind of picture that you're painting of what the possibilities could be and potential if the digital medicine model is correctly integrated and taken advantage of from the health system perspective. Now, before we wrap up here, I wanted to look a bit further into the future as well. With the last minute or two, how do you, you see digital medicine being integrated into more of the standard primary care over the next five to 10 years? What are really some of the exciting possibilities and potential there?
- [24:33]
B
Yeah, I think it's, you know, basically bringing these digital medicine clinicians fully into the primary care team where they become active, you know, co participants along with the primary care provider, in all order to not only reduce the 27 hour day and the burden of that, but maybe even allowing the expansion of primary care panels. And the reason why that's important is because right now there are not enough primary care physicians in the United States such that every single patient in every single person in the country could have their own primary care provider. And the only way that it would become possible for every person to have their own primary care provider is to transition to a primary care team where a primary care provider is able to care for a larger panel and yet still deliver care effectively. And I believe the only way that becomes possible is with the complete integration of digital medicine, medicine and digital care into primary care and then embracing future technologies like artificial intelligence, generative AI to also be able to help us to figure out how to remove as much work as possible from the plate of a primary care doc so that the plate doesn't fall and break, but rather is able to be, you know, balanced perfectly by kid, you know, while still caring for a larger panel and giving everyone access to the primary care that they need. And deserve.
- [26:20]
A
That's fascinating. Dr. Cole, thank you so much for joining us on the podcast today. This has been an amazing discussion. I learned a lot and a lot of exciting things happening. So I appreciate your time today, and I look forward to connecting with you again soon.
- [26:31]
B
Thank you for having me.