← Becker’s Healthcare Podcast
Becker’s Healthcare Podcast
Ryan Ribeira, MD, MPH, Medical Director and Clinical Assistant Professor at Stanford Health Care
00:14:17
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- [00:00]
A
Hello, everyone, and welcome to the Becker's Healthcare Podcast. I'm Scott King, thrilled today to be joined by Dr. Ryan Ribera, medical director and clinical assistant professor over at Stanford Healthcare. Dr. Ribera, how are you doing today?
- [00:14]
B
I'm doing all right. Thanks for having me. Of course.
- [00:16]
A
Thanks so much for joining us. We have a lot of big topics and trends in healthcare to get to, but before we get to the questions, I was wondering if you could please tell us a little bit about your background.
- [00:26]
B
Sure. Yeah. Yeah. So, you know, as you stated, I'm an emergency medicine doc. I'm the medical director of the adult emergency department over here at Stanford. But I think maybe worth noting that I've. My whole career, I've kind of straddled a few different spaces. So, you know, came up as a resident at Stanford, did an administrative fellowship here and obviously continued on in traditional healthcare operations. Got a master's in public health, focused on administration as well, but also have spent a lot of time in the tech industry. I used to be a program manager over at Google. I've been part of a number of health tech startup companies along the way. And then currently I'm also the medical director for digital health for acute care here at Stanford Healthcare and also run kind of our industry partnership program as well. So we've kind of viewed things through both lenses. How can we use traditional operations to expedite throughput and improve care, and then also how can we leverage technology, especially in the current environment, to do those things better?
- [01:29]
A
When you see how emerging tech has kind of taken healthcare by storm, are you really glad that you. You spent some time in that space before you got to where you are now?
- [01:37]
B
Yeah, absolutely. I mean, every one of the things I like about technology is it always seems like you're just right there on the bleeding edge of some really cool stuff. And so, you know, right now it's AI, obviously, but previous to that it was telemedicine, and, you know, previous to that it was clinical informatics. And so I think it was exciting then, but it's even more exciting now.
- [02:00]
A
Yeah, 100%. We're always, we're always waiting for that new. That new shiny object. It's always about to come and we do get it. And then there's another one. What opportunities and headwinds do you have your eye on right now in health care?
- [02:13]
B
Yeah, you know, I mean, I think definitely the, you know, from my position in the emergency department, one of the biggest headwinds is this kind of national crisis we're having around Boarding and capacity. We experience it at Stanford, but we're not the only ones. I mean, emergency departments that are half filled, sometimes three quarters filled with, you know, overflow, boarding patients who are, you know, admitted at the hospital and, you know, the. The associated problem of just inpatient hospitals not having enough space either, either because they lack the physical place plant to do it or because they don't have sufficient staffing to utilize their beds. You know, I think the other thing that we're grappling with at Stanford, and I know we're not the only ones, is, you know, the acuity that we see is rising. Some of that is due probably to an aging population. Some of it is, you know, a little bit of a mystery. It'd be interesting to see, you know, from a population health perspective when we look back on this era, post Covid and study it, you know, why acuity seems to be rising in EDs across the country. But it is definitely true for us, and I know it's true for others. So how do you deal with that? More people coming in the door. Those people are sicker than they've ever been, and you have to manage that with fewer beds than you've, you know, than you're used to having to care for that population.
- [03:36]
A
Yeah, and you mentioned, you know, kind of needing more staff, influx of patients. So, you know, a lot of times that's acquired through growth, obviously. So how are you thinking about growth and adding value to your organization?
- [03:50]
B
Yeah, it's interesting. You know, in the emergency department, we're one of the only, you know, clinical groups that really doesn't want to grow too much. I think. I think we would prefer if there were fewer patients coming in the door, or at least if the patients coming in the door, you know, were ones who, you know, truly needed our care. You know, unfortunately, obviously, a lot of the growth that we experience is due to other downstream challenges in our healthcare system and patients not being able to access the right. In the right place at the right time. And so, you know, for us, it's less about how do we get more patients in the door. But, you know, given that there are more patients coming in the door, how do we grow our functional capacity to care for them? Because, again, without being able to usually grow our physical spaces, it's about how can you see more people with the same resources. And so a lot of times that is just traditional operational efficiency. You know, how do you triage more efficiently? How do you move patients through the standard phases of care, get their labs quicker, their imaging quicker, their consultations quicker so that they can get dispositioned and you can make more space for the next patient? Sometimes it is utilizing technology to develop novel treatment pathways. At Stanford, we have a virtual visit track, so patients who show up to our ed, if they meet criteria, can get funneled over to a. A telemedicine track where they sit in front of a computer and they're seen virtually by a remote emergency physician who can still get them all the care that they need, and those patients get through a lot more quickly and get home. And then it's also, you know, how can we think about. Because the walls of our ED aren't going to change. How do we expand the care we provide beyond the walls of the ed? How do we intervene when a patient is considering emergency care and either make sure that they come in, they get it, or make sure that if they don't need to come in, that they're still getting the care that they need outside of that. So, for example, again, at Stanford, we have set up a program where we've got a telemedicine card at a local skilled nursing facility. And when they're contemplating bringing a patient into the ed, they instead put them in front of the cart, and one of our EM docs is able to very often care for them there on the spot, preventing an ED arrival. And so those are kind of some of the ways that we're thinking about, how do we, given that our volume is expanding, how do we expand our ability to provide care for this larger patient population with the same resources?
- [06:24]
A
Do you think the virtual visit track has already made a big difference in terms of efficiency?
- [06:29]
B
Oh, yeah. I mean, so. And you kind of have to think of efficiency a little bit differently, actually, when you're talking about things like the virtual visit track. So, you know, is. Is that doc churning through as many patients per hour as they are in some of our other zones? Frankly, no. If you look at the statistics, however, you know, when you've got somebody who is seeing sometimes 22, 23, 24 patients a day, and they're doing it just with a cart, no ed room necessary, that's huge. I mean, that is 10% of our daily arrivals, and we don't even need a bed. And so it's definitely resource efficient. When you're talking to. When the resource is the geography, it's tremendously efficient on that front. And then it's also very efficient when the resource you're talking about is that patient's time. They get through much faster and they don't crowd up our ED waiting room quite so much. And then actually it's turned out that it's very popular from a patient perspective as well. It's a surprising to us, but it continues to be our most popular zone in the ED right now. And so when it's safe care, the patients like it and it's very efficient, I mean, it's turned out to really hit on all fronts.
- [07:51]
A
Sounds like it's popular for good reason there. Let me ask you, what is one risk or investment do you think is worth making this year?
- [08:01]
B
Yeah, I mean, so I, I think there's, there's probably a few, a few things to think through here. But I, I would say this year going into 26, I think it's a very important time for EDS to start integrating things like predictive analytics into their workflows. This is the kind of thing that I think three, four years from now even will be absolutely standard. And emergency departments that have a bit of a jump start on how to utilize them are going to be, you know, ready for the continued increase in, in patients coming through our doors. So, you know, we're, we're planning to implement in the coming year, for example, predictive analytics at the point of triage to help us determine whether a patient is appropriate for things like our virtual visit track or our vertical work streams, or can they just be discharged from the waiting room or do they, we need to send them to one of our high acuity areas so that we can make sure we're utilizing, you know, our care spaces most appropriately. We're looking at utilizing it upstream at the hospital capacity level so we can better predict ED inflows, surgical inflows, transfer center inflows, and therefore, you know, kind of pre poll levers some of our interventions when we anticipate we are going to have heavy capacity days rather than being quite so reactive. And I think by doing that will harvest a lot of efficiency. And then, you know, there's a lot of other opportunities here. I think from like an ED operations and management standpoint, using AI for charting, I think for us we've been doing this already has produced more thorough charting that is more amenable to being coded appropriately so you can get paid appropriately for the work that you do. And then, you know, I think once you've got AI that's got access to some of the, you know, eating notes and also the structured data in the chart, there's a lot of additional opportunities I think as well, a lot of additional opportunities as well for us to start predicting things like, you know, which patients might benefit from early palliative care intervention, which patients are likely to need ICU care, and therefore we can move them up there more quickly and also, you know, convey that information to the, you know, the hospital capacity leads or even which patients are likely to have a bad experience while they're there. So we can utilize kind of our resources well to help smooth some of that over and make sure that all of our patients are getting the care that they need in the manner that meets their needs. So I think there's a lot, a lot of opportunities that it's worth dipping our toes into if not jumping in with both feet in 26, because I think these trends of increasing volumes, increasing acuity are not really going to stop. And so these are the types of tools we got to get facility with quickly so that we can not be overwhelmed in 27 or 28.
- [11:11]
A
And the last question I have for you, Dr. Rivera, where do you see the best opportunities for growth in the future?
- [11:18]
B
So I think we've talked about one, which is predictive analytics, AI enabled care and operations within the walls of the ed. I do think another area, again, growth is interesting concept in the emergency department. So another way that we can think about how to extend our capabilities is through this idea of expanding emergency medicine beyond the walls of the ed. And we talked about a few of those ways that that can be done, I think through telemedicine, you know, tele sniff programs, tele EMS programs, which are very analogous on the other end of the spectrum, hospital at home programs. And that's something also that we're looking at at Stanford is, you know, discharging people from the hospital a little bit earlier than we otherwise would. But we do that because we have a remote provider who can check in on them and get them the last, you know, vestiges of what they would have gotten inpatient. And we're looking at doing that from the ED as well, so that we can take patients we might have admitted to a physical, you know, clinical decision unit or an OBS unit and instead do OBS at home. I think those, those are some big opportunities that we have the technology to do now. It's just about the workflows. And then on the other end, you know, the spectrum, I think there's, in addition to things like telesnaf and tele EMS control, there are, I think, a lot more opportunities through digital health and telemedicine to provide patients with, with tools and education in real time as they're contemplating ED care that can prevent visits that are unnecessary and get patients a little bit better targeted. I know at Stanford, a lot of our outpatient clinics have now converted to telemedicine, and many of those, in conjunction with remote patient monitoring tools, are able to identify patients who are, you know, having chronic issues with their chronic diseases escalating or, you know, other concerns that might eventually lead to an emergency presentation, and they're able to intervene remotely before that happens. And so I think those are, again, it's not about expanding space. Of course, if you're an ED has the opportunity to expand your. Your care spaces, you should probably take it. You're probably going to need it, but most of us don't have that. And so it is extending our ability to care for patients into the pre and post ED visit to make sure that they're getting the right care in the right place at the right time and making sure that the precious ED space that we have is utilized for those who need it most.
- [13:54]
A
Dr. Rivera, thanks so much for joining us on the podcast. It was a great conversation. I look forward to working with you again soon.
- [13:59]
B
Yeah, thanks so much for having me, Sam.