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Becker’s Healthcare Podcast
Using Virtual Care and AI to Reduce Burnout and Improve Hospital Care with Dr. FJ Campbell
00:29:34
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- [00:00]
A
This is Laura Darda with the Beckers Healthcare podcast. I'm thrilled today to be joined by Dr. F.J. campbell, Chief Medical Officer at Ardent Health. Dr. Campbell, it's a pleasure to have you on the podcast today.
- [00:10]
B
Thank you, Laura.
- [00:11]
A
Now, I'm excited for our conversation. I know we're going to be digging deeper into AI technology and some of the real, real world benefits that you can get into in digging deep into those practical solutions that AI can today truly, truly solve in the healthcare space. But before we dive in, can you just briefly introduce yourself and tell us a little bit more about Ardent Health?
- [00:31]
B
Sure. I'm an emergency physician. I've been with ardent for about eight years now. The company 30 hospitals across several markets. We really focus on forming partnerships with academic centers for improving community assets. We very clearly have achieved success with that model. It's novel. It's also effective. Our hospitals really are a cross section of what you're going to find in the United States, which means we also have a cross section of the problems you encounter in delivery of healthcare in the United States. Notions of virtual care and AI are very attractive now and they're very exciting and they pull out the futuristic interests of so many people. But in our world with our practical problems, we need practical solutions. So I look forward today to communicating how virtual care and AI specifically are bringing true, measurable, both clinical, operational and financial benefits so that more people can engage in this work. Because candidly, I need more people engaging in this work. We need a community of learners on this and we don't have enough facilities engaging in this. So that's very much why I wanted to speak to you today.
- [01:42]
A
I love that. And I think this is a conversation that certainly has a ripple impact on so many hospitals and health systems and organizations that listen to our podcast regularly. Because you're right, I mean, looking at the technology, virtual care, AI being rooted into solutions and spaces where you can truly find the biggest benefit is the transformational aspect of it. Now, I know Ardent Health announced plans to launch an enterprise wide virtual physician, nurse and patient observation platform. Can you talk a little bit more about that initiative and how it will transform care delivery?
- [02:13]
B
It started out of COVID Like so many things, there were some positives that came out of COVID and what we realized is what we could do in terms of leverage, leveraging a telehealth visit for meeting our staffing needs in our and our patient access needs. But we were really also concentrating on the realization that our nursing staff had just become completely burned out. There was an untenable amount of volume of work for nursing staff to do, nursing leaders to manage a higher level of acuity than we had ever seen before. And we had gotten into a cost curve that had become unsustainable. And with that, the challenge that our board put in front of us very proactively was we have to find a system for load balancing nursing care. And very quickly we arrived upon virtual nurses. So what our virtual nurses actually do, we believe it on the notion of technology should be made by end users for end users, and that the real customer there is the end user. So we went to nursing leaders across the enterprise and said, what do you want to take off of your checklist? What do you want to take off of your to do list? And the areas that quickly surfaced were we can't do admissions well, intakes well on patients frequently because we're interrupted. We can't do discharges well frequently because we're interrupted. And when it comes to maintaining, you know, purposeful rounding, we can't necessarily maintain the schedule that we would want to. So it was those three areas that we effectively executed on. And what we found, what I found when I would go to the markets with the units where we basically launch, where we'd have, you know, virtual nurses, we would have RNs, we'd have PCTs, sometimes we would have LPNs or LBNs, depending on where you are. Nurses would come up to me, grab me on the arm and be like, and pull me over. You actually brought me technology that helped as if it was a novel concept, which for so many clinicians, it is. Okay? And they would show me their to do list. Like, you see all these boxes here? The ones that have red check marks through it, the virtual nurse took care for me. And the ones that have the black check marks I took care of for me. This has literally allowed me to concentrate more on my work and identify where we have potential safety gaps, where we have throughput gaps, where I can actually connect with a patient in a way that I haven't done before because I can actually, like, not be frantic. So turnover on those units went down. But here's the really, like, hard dollar impact, okay? So on our units that have virtual nurses, if you look at the cost of, like, nursing care, which includes contract labor, premium pay, our regular FTE nurses and PCTs or areas, those are nursing expense. Nursing expense per patient per day has gone down consistently between $15 and $30 per patient per day. This is more than covering what I have to do on virtual nursing. Now let's move on to virtual sitting for a moment and which actually we refer to in our organization as patient safety attendance. Now, the ROI for that has been proven by another number of organizations. One of the first to really achieve success in proving that RRI was avasure. Okay. I mean they, they wrote the book on that. And what you can find here is when you're using virtual patient safety attendance, first of all, the AI algorithms have become much more effective at seeing precursor activities for a patient that can predict who's going to fall, which means you can have one patient safety attendant virtually monitoring several patients. So what we're doing is we're taking people who had been strictly patient safety attendants and sometimes that sitter could have been a nurse because that's all we had, or a pct. So we're now having our sitters. If you're going to be a sitter, you're either going to be someone who is a PCT or you're working in transport or some other capacity in the hospital, but you're not a nurse at $39 an hour. We're a contract laborer. Good God. Okay. So to that end, we have a system that is allowing us to do sustainably more effective identification of patients at risk for falling and at a cost structure that actually is going to create a situation where when we look at what's going to drive covering our costs for all of our virtual care platform across all of our enterprise, our break even point is going to come well within our contract from virtual sitting savings alone. And no, I cannot give you those exact figures because I can't and I, I won't. Okay? But I can tell you that is what you can count on. Okay? Certainly with organizations like Avishure or Helocare, that's what you can count on. I have no disclosures. All right, so with that in mind, you have a cost sustainable model for sitting that actually creates a cost sustainable model for both nursing physician and attending from the savings of that. But you're also going to be looking forward to about a 20% reduction in falls. Remember, for what we all have to do in any kind of healthcare system, if you want to have a sustainable transformation of care, you need a sustainable economic model and a clearly measurable clinical impact. So let's move on to virtual physician for a second. When I think of length of stay and I'm in a smaller community hospital, okay. It is a really challenging circumstance to have a whole host of capabilities. When I think of emtala, I think of capability and I think of Capacity, Capacity, Do I have beds? Capability, do I actually have the clinical resources? Community hospitals, as long as they could staff and have, you know, a capacity to break even, even, they will bring more patients in. The challenge they're going to have is will they have the clinicians and specifically the specialists to execute on that care. If I have a hospital that's a smaller facility in a more distant community, and ultimately I have a cardiologist only available three days a week, my length of stay is going to go up and my ability to retain higher acuity patients is going to go down. And EMS will in time know that and go past my hospital. But if I'm in a situation where I have virtual care capabilities per room, which then allows me to have virtual sitting, and that's going to drive your sustainable return on investment, virtual nursing, which is going to supplement that, the, the real. And at that point, now I can afford to have all these systems. The real benefit becomes I can now retain higher acuity patients because through a virtual physician, I have that cardiologist seven days a week, I have that nephrologist, I have that neurologist, I have that infectious disease tending or pulmonologist. Now, people often come to me like, what if the COVID waivers on virtual care go away? Well, that would be a tsunami event that would be very detrimental to the entire healthcare delivery system in the United States. So I'm not betting on that one. Okay. But with that in mind, what you're going to find, especially as we're looking at rural facilities and you think of the funding that's going out in terms of the rural health funds, that $50 billion over five years. If you want to make sure you're protecting a rural community, you want that hospital to stay open. In rural communities, a hospital, even a 50 bed hospital, might be the only destination for a hospital for two hours. And a lot of the United States experiences that. So under the circumstances, if you want to protect rural communities, for the love of God, you better protect those hospitals, which means you have to get the specialist to them. And the only way to defeat time and geography distance is through virtual care. Because what's going to happen is you're going to actually be bringing specialty care to those regions. So when people ask me about, hey, how is this going to improve patient safety? I'm like, do you have any other solutions to that? If you want to really make sure that we have an unsafe environment, let's make sure that specialists can't get out to these communities. So when people ask me like, how is virtual care actually going to. Like, how are you going to make sure it maintains patient safety? I'm like, like, in comparison to what we have now. Are you joking? What we have now is not safe.
- [11:40]
A
That's such a great point. And definitely having that opportunity to bring in more virtual care and expanding that capacity for nurses and physicians to do more within the walls of the hospital as well as on the outside and connect with patients, I know, is a huge, huge win for the health system overall. And I'm curious, when you look at incorporating all of this into the daily workflows of the clinic, physicians, patients, et cetera, what were some of the challenges that you ran up against? Because I know it's easy to say, hey, this is going to be helpful for you, but to actually then get adoption and make sure you've got the right systems in place in the right people leading these efforts is critical. So I'd love to hear a little bit more about how you've been working through some of those things and what you were really able to accomplish with the right plan in place and leaders that were leading the charge.
- [12:32]
B
It was easy. Let's start off with the patients. Here's what the patients say. Wow, someone actually was able to talk to me for a full conversation. I mean, that happened, like, on day 0.6. The patients immediately gravitated to it. All ages, all backgrounds, you name it. The first thing, they immediately understood what was going on. And the first thing it would say is, I really appreciate the fact that I could, like, talk to you this whole time. Like, it seems like you're really paying attention to me. That's the gist of what we got. I mean, that happened right out of the gate. Mean, intentional design really helped. Like, we didn't have people who thought, wow, virtual care, it's really cool. Here's what I think we should do. And basically push it down. It was, okay, let's talk to people who are actually going to be doing this and actually going to be using this. What do they want? Nurses, by definition, are incredibly pragmatic individuals. They've got a list of things they have to do, they have to get done, and they will MacGyver their way to it. And they always do. And they're like, we're going to take care of this. We're going to have good intakes, so we have a better history, a better understanding the medications are on, a better understanding of the concerns they have, which gives us a better understanding of what the vulnerabilities are and when we get to the end, we're going to have a better discharge. Because so often. And even hcahps looks at this like, how well did the patient appreciate along the way what their care plan was? Well, they can talk it out with a virtual nurse during their stay. And equally important, do you understand what you have to do when you leave? These are well measured elements and they are the specific areas in each caps where our units that have these tools are rising. And that means, like, the thinkable, like it's logical, it's believable, is actually taking place because we're dedicating resources to it. So from a nursing perspective, out of the gate, when, like, I'll go to units and nurses will be like, I know, I'm like, hey, a number of our hospitals, we have a competing hospital, like literally across the street, like you can hit it with a baseball without even trying. Okay, so here's the deal. I'll say, like, what do you think of this? Like, how, how if we took this away, what would you do? And after they tell me about how they would flip out and they're like, I'll give you an example. I'm getting offers right now from hospital X, which was across the street, for three more dollars an hour. I'm not taking that. Now, I'm not going to tell you the game of what we played in terms of how much would you take. But most people are like, here's why I want this. And it always gets back to something very tangible only in the eyes of the end user. They're like, I get to have lunch, I get to go home on time. And I'm not just going into this frenetic pace all day. One of the things that we look at, whether it's the sitting element, meaning patient safety attendant, the nursing element, or the physician element of virtual care, the goal here has been to reduce cognitive burden. Actually, we got that page from research that was done by NASA. The capacity to reduce mistakes and reduce risk is clearly associated with reduction of cognitive burden, which was a major focus for us. Our goal here, whether it's with nurses or physicians in virtual care, isn't to make them more productive, although that does happen, or simply just to reduce cost, which has clearly occurred. The bigger threat in my mind, I look at two lines. There is the line basically demonstrating the sheer number of individuals who are going to be Medicare eligible by 2030, and that's just going up and it's 67 million people. And another line that's not very good and concerning is by 2030. The average age of physicians is going to be one of the highest, meaning closest to retirement that we've ever seen before. So as we're peaking on our Medicare age population, we are peaking in a population of physicians and nurses who are going to be considering retirement. These tools aren't just about, you know, what we have to do to sustain our care. These tools are very specifically about, I need to make sure that people want to keep on being physicians and nurses and more prominently stated physicians and nurses who actually want to work in the hospital. Because working in a hospital is an incredibly challenging experience daily and certainly over time. So a major focus for us is how do we reduce the cognitive burden that's going to allow us to retain our workforce. So they want to be in the hospital. I know you wanted to. So that's the whole story on virtual care. I know you wanted to get into other elements of AI, which if you thought it was going to be rather transactional and boringly pragmatic on virtual care, you should see how boringly pragmatic I am on AI.
- [18:02]
A
Absolutely. I love it. No, I think especially looking at AI, there's so much opportunity right now to become more efficient as a health system and to deliver healthcare better, but it doesn't always take that transformational, huge pie in the sky ideas are really big problems that are simple solutions but make such a big difference and have a real, real impact on patient care and how the organization is run. So I'd love to hear some of the things that you've been doing in ways that you've been looking at AI that is truly beneficial across the board.
- [18:32]
B
AI scribe, full stop. Okay. And we'll get into that for a reason. But when you think of what clinicians, if you start ranking when they get to the end of their day and they're like, today was awful. If they had an awful day, like, why was today awful? Tell me why today was off. They will talk about documentation and the amount of time they have to put into that. On the physician side, it's what they have to deal with in terms of authorizations. And what's gotten lower on the list would be malpractice concerns. And the fourth would be just like the sheer flood of patients who have higher acuity conditions. If you were going to ask those kind of questions, like 20 years ago, you wouldn't find the malpractice concerns and just the sheer flood of volume in high acuity patients at the bottom or the closer to the bottom of the list, they would be at the top. Of the list, they have been supplanted by just the sheer grind of documentation burden. And you know, when you look at all of the payers out there, okay, you know, you start tracking what's going on in their stock price, you're going to start seeing something that's not very shocking. And it's that their denials activity and their authorization activity goes off the hook. And that means physicians have to spend that time working through that. Now, what's really, really important to appreciate here is when you're looking at the payers, they are exquisitely connected into AI activities to basically demand requests for information relative to an authorization or request for information for inpatient versus observation status. And what we're going to get into, and this is the most comedic element of all of it, you're going to have AI tool versus AI tool, spy versus spy. That's one component, the AI Scribe component that's so meaningful goes back to cognitive burden and the pragmatism of retaining your workforce. Now, right now, AI Scribe focuses overwhelmingly on physicians in their clinics. And here's what we saw, okay, There are a number of very good tools. We happen to use ambience to that end. Here are our results. So with that, clinicians are, without even trying to seeing about one to one and a half more patients a day. We weren't looking for that. Remember, our goal here isn't to make them more productive. Our goal here is to reduce burnout and retain them. Because there is going to be a time where if you aren't showing what you are doing for physicians in general to improve their workflows. And we'll finish up on that. You're not going to have of medical staff. So we brought in AI Scribe activity specifically to drive retention, reduce burnout, reduce cognitive burden. And that happened right out of the gate. Like, we went from 100 physician pilot to commitment towards 900 clinicians. Like, my CEO was getting texts from physicians saying things like, I saw 17 patients before lunch today. And I know it was before lunch because I've never gotten lunch in the last five years. And I actually got lunch today. You would be getting texts from, I'm actually at home having dinner with my family. Go back to the virtual nursing piece. What hit them in terms of why they love it is because it hit him in the field. For the nurses was, I get lunch, I go home on time. And it's the same thing for the docs. And they can say things like, I'm actually having conversations with my patients. And these AI systems are so effective in their mapping, they're actually creating far better notes than they were ever creating before. So, sure. The EM coding also went up so very confidently. We are going to be at a break even from this. And that's without even getting into the kind of MA contracts that are coming in the future where RAF scores are really going to matter and what you're basically doing to achieve certain population health metrics that are going to be valuable to an MA contract with your RAFT scores. That's when the AI scribe tools are really going to be showing their benefit, like generating like a 4, 5, 6 x ROI versus a 1 1/2 x ROI right now. But it is more than paying for itself. What's going to happen next, though, is we have to bring that technology into the hospital, and you're going to see that with hospitalists and ED attendings that will also pay for itself. But if we're really going to have a next step in the hospital, it's going to be about how AI scribes are getting into nursing documentation. And that is a hot area of development for us because I worry a lot about being able to recruit physicians. I do. I worry infinitely more about being able to recruit nurses. Okay, where are we at?
- [23:59]
A
Absolutely. That's fantastic. And, you know, definitely makes a lot of sense. I appreciate you talking through AI and looking at even what the next steps are for the future. Are there any other big challenges that you see trying to tackle next with technology?
- [24:15]
B
Getting paid, that's important. When I think of the kind of systems that are out there, like, here's an area of healthcare that we just generally are not good at. And I'm actually really policing my language right now. We just aren't good at it. And that's vital signs. It's funny, it's because they're vital. But to actually improve the deterioration indexes that exist out there, and there's some really, really good ones. There's the stuff in epic. Cerner's developing some. You know, you've got another product out there called Alert Watch. I mean, they're a really like, they're all really good, but they all require fuel, and the fuel would be a flood of data. And the best data of all for these deterioration indexes are vital signs. So we need to have actual technologies and not just in the ICU that can monitor a patient. And it's funny, the most. My new. My favorite vital sign is respiratory rate, which is ironic because for most clinicians, they snicker and say, yeah, the respiratory rate was 16, 18 or 20. Don't ask. Okay. What? It's not the subtleties in respiratory rate we have found with the technologies we use. And anyone who wants to know what the technologies we're using are can look us up. Okay? But it's the ability to capture respiratory rate, heart rate, even skin body temperature. And one day blood pressure and pulse ox. Every minute allows for these systems to see the subtle changes. Neither increases in these rates or decreases in these rates. And when that occurs and when they actually happen more and more, you know, compressed over time, those patients who are showing those changes are, are actually demonstrating a higher risk for eventually compromising their overall condition, requiring critical care. Okay? Getting paid, the ability to actually have that technology to monitor those patients more effectively, to use those DI tools, you need automated patient monitoring. Having the dip vital signs flow into Those systems not four times a day, but 12 times an hour. So it is a voluminous change in how we execute on care to identify the deteriorating patient. It's like comparing the pony express to a cell phone. And that's absolutely within our reach. And the feds have to figure out how they're going to pay for that. Because that kind of wearable technology, you will then wear it home. Now, for what it's worth, the Rural Health Fund, there is no such thing as any of the states applying for the Rural Health Fund dollars without including something along the lines of wearables. Where I think it's a little misguided is you're talking about the general utilization of wearables. I'm like, no, no, no, no. I mean, there's a value for that, but it's not nearly the value of you just had a patient leave the most expensive place on planet Earth in health care, and that's a hospital, you want to make sure that they don't have to come back at least for 30 days, if not longer. So the wearable technology, in my view, will be much more generous in creating return on investment for the federal government if they're saying it's wearables from hospital to home. So a challenge there is getting to that next component which is on cognitive burden. So it was, what do we have to do to load balance? What do we have to do to meeting capacity? What do we have to do to load balance and capabilities across an enterprise. And then the third element here is in the trifecta, how are we doing a better job of identity, identifying the deteriorating patient? Because there is not a nurse out there anywhere who goes through a whole week without worrying a decent amount about who's the patient that I'm not going to see about to go down the tubes? There's no hospitalist or any doctor out there who doesn't go on a ship. And being like, which one is the one that's going to catch me off guard. So being in a situation where you have literally technology that's watching your back to help you identify the deterring patient hours before you could is the third leg of the stool. We have to balance capacity, the volume of patients capabilities, the resources to take care of highly acutely ill patients, and finally the ability to identify the ones who are deteriorating. Those three things that we're trying to address greatly reduce cognitive burden, sustain our staff, and we feel like we have found sustainable models to pay for this stuff. And I want more people to know that because we need more people doing this work.
- [29:11]
A
Dr. Campbell, that's amazing insight and certainly such a strong, strong reminder of what's truly important and how technology can next really benefit what you're doing in the patient care level as well as for providers. I really appreciate your time today, Dr. Campbell, and look forward to connecting with you again soon.
- [29:28]
B
All right, thank you. Take care.