Exploring Healthcare Transformation with Dr. Eve Cunningham and Remote Patient Monitoring

[00:00:16] Hello and welcome to The Uprising Show. And today I have a very special guest, Dr. Eve Cunningham. Dr. Cunningham, welcome. Thank you for having me here. It's really exciting. I am very, very excited. We were trying to make it work for a bit and finally it happened. So I'm super excited about it. Why don't we start with a little brief introduction from you for our listeners?

[00:00:42] Yeah, so I am the Chief Medical Office of Cadence, which is the largest remote care delivery system in the country. So I know we're going to talk about them a little bit more. I just recently stepped into this role. But prior to that, let's go back almost two decades. I'm an OBGYN physician by training and practiced for a number of years as a physician. Really enjoyed that period of time in my life and moved up through the ranks in physician leadership.

[00:01:13] First, managing mostly women's health and pediatrics and urgent cares at one of the largest health systems in the country, Common Spirit. And then eventually moved over to Providence about eight years ago to take on a leadership role as chief medical officer of one of their large multi-specialty medical groups. And then after doing that for a couple of years, I moved over onto the technology innovation, corporate innovation space, and eventually led the virtual care and digital health team,

[00:01:42] which had a large portfolio of virtual, digital, telehealth, hospital at home, remote care services. And I recently took the leap to Cadence. It's been almost, we were just counting, this is week four. And I'm really excited to talk to you about what Cadence is doing and why I took this leap, because I really think that they are doing transformational work that's going to make a huge impact on patients.

[00:02:10] Yeah, fantastic. I think in my heart, I have a special corner for physicians who come out and become tech leaders. It's just a different dimension. It's a different skin. And this is a different, you know, scale. You level up to the next level. Physicians don't necessarily go well with tech as much, most of them. But now we are seeing a wave of physicians who are really setting the example for everyone.

[00:02:37] So you are certainly one of them. So I'm excited to have this conversation. Before we go into more of professional aspect, I know, and I was reading your LinkedIn profile. It has, you have incredible mix of tech, healthcare and innovation experience. But before we go into all that, let's go back in time. Where were you born and raised? Were you entrepreneurial as a child? Were or was either of your parents an entrepreneur?

[00:03:06] Can we start there first? Sure. Yeah, no problem, actually. So not entrepreneurs in my family, necessarily. I was born and raised in Tucson, Arizona, which was a fantastic place to grow up. And my family is full of politicians and lawyers. So my dad's a retired politician. My grandmother was a judge. She was on the superior court bench. My aunt was a judge.

[00:03:35] My brother's a city councilman. And my mom's an attorney. And when I told my grandmother that I wanted to become a lawyer when I was a kid, my grandmother was my first mentor. She said, oh, my God, we have so many of those in the family. Can you please find something else to do? But no, I grew up in Tucson. My parents, like I said, my dad was a civil servant.

[00:04:03] So I grew up walking door to door, bringing brochures to people's doors, putting signs out. When my dad was in the state house and the state senate for a number of years. And then he was chief of staff to two governors of Arizona. So we were quite involved kind of in that civil servant. I wouldn't say I'm a very political person, but I mean, I kind of grew up in that environment and watched from there.

[00:04:32] My mom was an attorney and had her own business. So there was some entrepreneurial aspects in the family from that perspective. She had her own law practice. But I actually wouldn't have ever thought about entrepreneurship as a kid, as something that I would pursue. It's something that sort of came about later on in my career. Not even like when I went to medical school. I never thought about doing that. I always thought I would go and work for a large health system and be an employed doctor.

[00:05:02] So this has definitely been something that has evolved over time. Though I would say that one thing that is unique about me in my career is that I see myself, until I came over to the health tech side, as an entrepreneur. Like somebody who would innovate from within an organization or an institution. Always trying to find ways to innovate internally as an entrepreneur.

[00:05:28] Do you think you have to do sort of like a little mindset shift? Because, you know, when you are a physician working in health system for several, several years, you just get and now it becomes a little difficult to like, can I take that step of entrepreneurship or entrepreneurship? Do you have to do some kind of special efforts from your end to make that switch?

[00:05:51] Yeah, I mean, I think that, I mean, there's a lot of doctors who are entrepreneurs who go into private practice. My husband just went into private practice a couple of years ago and he is so happy. Like he owns a, he and a partner own this business together and they're just having a ball. So there's a lot of physicians who have that mindset.

[00:06:11] But I guess for, for me, the, the idea of like going and like building a company outside of a health system from start, which I've seen some of my physician colleagues do that. Like they'll come up with an idea and, you know, they're working, they're seeing patients or they're in a leadership role and then they'll actually go out and like build a startup from scratch.

[00:06:37] That is something that was sort of foreign to me. I've learned quite a bit in the last couple of years just through working with the corporate innovation, corporate development team at Providence while I was there. And then also incubating some technology and some, some things internally at Providence. But it's not something that we're trained in, right? It's now there are some of these entrepreneurship tracks that are happening that you're seeing in medicine.

[00:07:07] And I feel like the younger generation in particular of physicians is much more attuned to that. We're seeing a lot of younger physicians just taking the leap and going out and joining startups or even like building their own startup. And it's, it is quite impressive for me to, to watch and to see, because that just culturally wasn't like the way I was trained during my residency and my, my clinical training. Yeah.

[00:07:33] And you obviously touched a little bit how you ended up, took the career in medicine, but what was like, kind of like the transition point for you as well? Was that the conversation with your grandmom that said, like what would be the, the going to make a career in medicine? And then also talk about like, what point did technology become such a central piece of your journey? Yeah.

[00:07:59] So the first part of the question is like, why did I decide to become a doctor? I mean, I make the joke about my grandma saying, she was like, we really need a plumber in the family. I was like, grandma, I am not going to become a plumber. Like that is just like not happening. But no, I went to college. I actually didn't really know what I wanted to do. And within that first year, I started taking biology classes and things like that. And realized that I wanted to go down the medical school track. And I actually became really, really fascinated with women's health.

[00:08:29] I read this book called Women's Bodies, Women's Wisdom by Christiane Northrup. And she wrote this book that integrated, it wasn't just a clinical approach to women's health. She integrated the wellness aspects, the holistic components of women's health, and how important it is to think about it and frame it in all of those ways, which I found to be quite refreshing and revolutionary. And at that point, I think I was about 19 years old, I was like, I want to become like her.

[00:08:59] I want to become an OBGYN. And, you know, went down the track to become a doctor. Obviously, there was a lot of support in the family for me to do that. My grandfather was a dentist. My uncle was a dermatologist. So I had a lot of like role models as well. I told you there were a lot of politicians and lawyers, but there were some other professionals as well. And then once I went to medical school, I mean, I tried to convince myself not to become an OBGYN because I have to tell you, it's not the best lifestyle in the world.

[00:09:28] Babies come out at all hours of the day and the night. But I couldn't convince myself to do anything else and really just fell in love with the specialty and enjoyed it for a really long time. But one thing about me that you'll see along my career trajectory is that I get, I find challenges and things that I want to do and I make that happen, whether it's a skill that I have to learn myself,

[00:09:52] like when I learned how to become a robotic surgeon or a care transformation program that I want to help stand up. So I have these things in my career where I take on challenges and want to do things. And then after I've like figured that out and gotten it to a scale and it's stable and if I can hand it off, I want to move on to the next thing. So that's kind of a little bit of that reinvention of yourself entrepreneurial spirit that comes out in me.

[00:10:21] And I would say that once I started going into leadership in medicine, it didn't start with technology. It started with transformation. How do we take the way we deliver care today, the way we practice medicine today, and make it better or change the way we're doing it? So for example, when I joined Common Spirit, we were keeping all of our patients for two,

[00:10:49] one to two nights in the hospital after a hysterectomy. And when I trained in residency, 50% of our patients got discharged the same day. So I initiated a same day discharge program. Well, there's a lot of change management that goes into that. You got to get the patients on board. You have to have education. The anesthesiologists have to support it. The nurses have to be on board with it. But once you get it going, it's better care for the patients because why do they need to be in the hospital for two nights if they don't need to?

[00:11:18] It's better for the hospital because you're not using unnecessary resources. And so we would do things like that. We built out midwifery programs and deployed them across different hospitals. We built out an outpatient birth center that was connected to the hospital so patients could have tub births and deliver in a hotel-like setting. We set up a group prenatal care program.

[00:11:45] We did all these things that I would call transformational to our delivery models and the way that we practiced. And then when I was done with that, because I did everything you could possibly do at that point in women's health, I moved on to leading a medical group. And when I was leading the medical group, I moved to Providence to do that. The first thing I did, I had five graduate medical education programs that were reporting up to me.

[00:12:12] It was the first time I had a GME, graduate medical education, under my portfolio. And I was like, we have to make sure this is 2018. We have to make sure that all of the residents are getting trained to do virtual visits because virtual visits are the future. And everybody looked at me and thought I was nuts because nobody was doing virtual. We were doing a little bit of telehealth in the inpatient, but like nobody was doing, oh, you can't get reimbursed. We don't have the right technology. I was like, no, we got to do all this.

[00:12:42] This is the new thing. Like eventually it's going to be like everybody has to do virtual visits. So I, when COVID hit, um, the only ambulatory virtual pilot happening in the system was at my medical group because we had, uh, stood up an ambulatory pilot. I convinced the residency to, to do it. Cause you know, I had a clunky workflow and like it was very time consuming, but we were

[00:13:09] the me's, we were the subject matter experts. And, um, when you ask about how I ended up with technology, what happened was here, I was doing all these care transformation things and trying to chip away at that. Let's do online scheduling. Let's do e-consults. Well, COVID hit and we had to go from being a brick and mortar 41 clinic medical group to virtual, like almost overnight. And I can't describe to you the pain of doing that.

[00:13:39] I mean, I still like have like some PTSD from it. It was very, very difficult. Um, not only was it difficult, but then COVID, you know, we had the waves and we had like different teams that had to go in and cover the hospital. And I knew that the technology could accelerate this experience and make the experience good. But the experience that we were having was just awful.

[00:14:06] Um, the technology that was being thrown at us was not very useful. Uh, it was clunky workflows. Nobody was listening to us when we were giving feedback and saying, we need to improve this, this, this, this optimize this workflow. It's, and we're the most expensive workforce, right? Like you want us like running full, full steam, but it just wasn't translating, um, to the folks who were making these technology decisions and kind of throwing stuff at us.

[00:14:34] And so at that point I was like, well, I know technology can make this better, but there's no clinicians at the table, um, while we're making these decisions. And it's all over in the news that Providence is, you know, um, very tech forward. So we had investments going on. And, um, so I just kind of pushed my way in and got the corporate development team to bring

[00:14:57] me on and, um, and learned as quickly as I could, everything I could about product development, incubations, pilots, user feedback, um, user centered design. Like it was like going to school again and, uh, really just leaned in and it was great because they took me in and I learned a bunch and we started, um, I brought cadence in, uh, about

[00:15:25] two and a half, three years ago to that system among other solutions that we brought in or things that we built internally ourselves. And I never looked back once I kind of went into the technology and digital health space, because I think there's a huge need for clinicians, uh, to integrate well with product and technology teams with operators, clinical operators, so that we're really develop, developing and designing

[00:15:51] solutions that make sense to clinicians and patients. And that can be adopted at scale. Wow. And, um, a couple of things here. One, uh, personal anecdote that I actually came from Germany, bringing a company to here. It was initially a telederm company and it was 2014. And even then it was too early, telederm. It was too early. So because nobody was buying it and everybody was like, no, we're not going to use telemedicine.

[00:16:19] How are we going to get reimburse? All that stuff was going on. So it took, uh, it took us until COVID to then bring back those features because we already built it back then initially. And then we moved back to being more of a messaging platform between patients to practice and starting from the front desk. So quite a story of evolution, how that evolved. But, um, but that, uh, uh, in your story, you mentioned, uh, I guess there is something interesting

[00:16:46] came up here. So you were able to kind of, I don't know if this fell on your lap, like, Oh, we have to do telemedicine programs or new tech, uh, or like, how are you kind of like, like, no, we need to do these programs because this will be the future. How did you see those? Because, you know, it takes, uh, it takes someone special to view all the problems and say, like, this is the one we're going to prioritize of this tag. So how are you telling me about it?

[00:17:14] Was it like more like a initiative that was going on at that time? Like, yeah, let's focus on building the solutions for the future. Or is it more like, yeah, these are the options and you had some insight that let's build this. So what was the insight there? Yeah. I mean, I think at the time, you know, when you think about the time around COVID and stuff, there, a lot of the technology was starting to evolve, but I wouldn't say that health systems had like a significant amount of

[00:17:41] experience, really understanding how they were going to start to bring these things in and integrate them. And everybody was learning right at the same time. Um, one of the things that I would say was a little bit of a superpower for me was because I had run a medical group and a clinical service line in the hospital setting, I had a pretty good understanding of how to speak the language of

[00:18:06] the CFO and like what things they're going to be looking for, looking at from a strategic perspective and how they're going to be viewing those things. And then I also knew enough to ask the right types of questions from a IS technology integration informatics perspective. And then I was learning like about product and you know, that stuff. And so I was able to kind of take all of, and then I had clinical expertise. So I was able to kind of take all of those things together and try to view

[00:18:35] things from a strategic perspective. But one of the things that I did try to do was make sure that I looked at things that were going to make the biggest impact first and prioritize those, which is part of the reason why I brought in Cadence because they were tackling remote care management for diabetes, hypertension, and congestive heart failure, which are like three of the biggest

[00:19:01] disease burdens that we have in the United States that we're not managing appropriately or properly in a traditional care delivery model. We know that we know that we can do a better job. And so it was like, that is a good problem to try to solve. So I tried to prioritize what we would build and where we would put those resources to things that had like a big, like had a potential to have a really big impact

[00:19:29] from a value proposition perspective, both from a quality outcomes impact perspective and financial ROI for the health systems. Because every health system today, I mean, they run on very slim margins, they have to be very particular about what they choose to do. And unfortunately, when you do it that way, that the good thing about doing it that way is it's strategic, and you're addressing a larger, broader population, some of

[00:19:55] these more specific, very specialty specific or nuanced use cases that don't reach as broad of a population, they just don't get prioritized. Now, they may end up being in the roadmap and in the queue at some point, but you've got to go after the big rocks first. That's kind of the way I view it. And, and, and that's hard because I'm an OBGYN and women's health is near and dear to my heart. So of course,

[00:20:24] I would love to bring in a menopause platform, but it's like, that's, that's just menopause. Like it's not, you know, this, and there's a lot of women with menopause issues, but still it's not broad enough. You, we, we can't, we can't have all these point solutions that we bring into systems. We just don't have the capacity. They don't have, those systems don't have the capacity to bring those in too many of them at one time, if that makes sense.

[00:20:50] Yeah. I think, uh, um, I've seen, you know, there's a lot of physicians who don't view it the way, well, you view, you viewed it most. Everybody wants impact, but I think it's like everybody is in like their own area of impact. They're looking at their own specialty. And so they sometimes get, you know, frustrated when they're like, why aren't you looking at my little, you know,

[00:21:15] small patient population that needs this thing and think of a jig. And I'm like, because the, the, the impact is 300 patients versus 30,000. Right. Um, and so we have to think about those 30,000 and like really address that need first. Um, unfortunately that's, that's where we've got to prioritize the work that we're going to do. Wow. Fantastic. I love that thinking. Um,

[00:21:40] now you mentioned cadence in your past, uh, uh, when you brought them up there, but now you are chief medical officer there very recently for tweak, you said, uh, so this, the company is working to scale remote patient care and reach 1 million patients by 2030. Uh, let's first start by what drew you to this opportunity, specifically this role. Well, I mean, I've, I've, I've been working with cadence for a couple of years. Like I said,

[00:22:10] I had brought them into the system that I worked at previously. And I, I guess I want to talk a little bit first about like the problem that they're solving. Um, we, we know that we have a shortage of clinicians. We don't have enough doctors and we know that 10,000 patients are aging into Medicare like every day. And we also know that we don't manage chronic diseases very well. And this is not a knock on anybody, not on cardiology primary care. It's the way that our delivery system is structured,

[00:22:40] but we spend over $500 billion a year on those three diseases that I was telling you about chronic hypertension, diabetes, and congestive heart failure. And less than 25% of patients with hypertension are on the right medications and, you know, optimally controlled. Only 50% of diabetics are in decent control and less than 15% of patients with congestive heart failure on there are on the

[00:23:06] appropriate medications, which we know is associated with, with increased longevity and lifetime. And the reason why is because we don't have a good system in place to get these patients in good control because bringing a patient in every two to three months to see them for their hypertension, diabetes or all three is not a sufficient way to get these patients in control. They need very proactive

[00:23:35] titration of their medications with multiple touch points that allow us to calibrate them over time. They need reinforcement from people checking in on them regularly, making sure that they're adhering to their medications. And we need more data about what's going on with them day to day to better make decisions about how to medicate them, treat them, coach them and counsel them. And so we actually have

[00:24:01] to break apart the way that we deliver care and reorganize it in a different way when it comes to chronic disease and healthy aging for that matter. You know, we're talking about our parents and our grandparents. How do we make sure that they're getting the best care and they're getting checked in on when they're at home? And so the remote patient monitoring codes for reimbursement with Medicare came out

[00:24:26] a couple of years ago and a little bit more than a couple of years ago, but there was a bunch of health systems that were like, Hey, we're going to do this. You know, we're going to, we're going to do remote care. And so we did this at, uh, they did this at Providence, you know, every other health system tried these little, um, pilots where they would bring in a remote patient care platform technology, usually only. And then the health system would try to stand up a program. And what they found was they had a lot

[00:24:54] of difficulty scaling it. They couldn't scale these programs. They might get 50 to a hundred patients enrolled. And then the people who are in the clinics seeing the patients and dealing with day-to-day operations. They don't have time, you know, to stand this thing up or the health system makes a little investment for a small team to do it, but then they realize that it doesn't pay for itself. So they're losing money on the program. So how do they keep it afloat? And what Cadence did was Cadence came in and

[00:25:23] said, Hey, we are at a, gonna have, we're at a size and scale and scope where we have thousands, you need thousands and thousands of these patients with your staffing model to make this run efficiently enough so that it can break even for everybody. So we'll come in, we will partner with you. We will act as an extension of your care team, your primary care doctors, your cardiologists, and we'll provide

[00:25:50] the remote care. We'll have nurse practitioners, nurses, and care navigators that can coach the patients, patients, titrate their medications for you according to agreed upon protocols. And then you still act as the primary clinician for that patient. We just extend your reach into the home. And at the end of the day, it pays for itself. You get reimbursed a little bit more than what we charge you. And then on

[00:26:18] the back end, we actually have been able to demonstrate reduced total cost of care. And I thought, well, gee, that sounds like a pretty good way of standing up a program for remote care at scale versus us trying to do it ourselves when we're not organized to do it that way. We don't have a technology platform that allows for it to operationally and logistically roll out at scale.

[00:26:45] And so that was like the hypothesis. They were very early stage when we brought them in, but within two and a half years, three years of being on the journey, that is exactly what has been proven out. They now, we now have almost 40,000 patients that we're monitoring on our platform. So it's at a large scale. We have all the operations, logistics, technology capabilities that were designed from

[00:27:14] the ground up, not encumbered by incumbents or legacy platforms built from the ground up and designed for remote care delivery specifically. And we can plug into these different health systems. We have almost 15, we have 15 health systems that we are partnered with big names across the country where this type of

[00:27:38] care model really resonates with them because it's a, it's a low investment on their end. They obviously have to invest in like change management and like getting some of the programs stood up, but, but it's a low risk investment for the health system to get a new care delivery model stood up and deployed in a scalable fashion with a, with a great partner like us. Wow. Uh, this is really fascinating.

[00:28:05] So my first impression was this is more of a tech or med device, but there's a whole, you're getting workforce. It's like, it's like a, it's like a, it's like a, if you think about when you build a hospital, right, there's a ton of logistics and infrastructure and like you're building all of these different pieces and components to be able to deliver the care, right? We're basically building a virtual

[00:28:34] digital delivery system to deliver at, and it's not just technology, it's technology operations and the services, the clinical services together. Yeah. Um, how is the response being, I mean, you were on the buying side for this solution. So it's a great question for you just in general, like, was it at any point you were like, Oh, this would be a risk in terms of like, how do we trust external workforce, which is not kind of our part of like,

[00:29:04] how do we make sure the training levels and compliance and quality? Uh, all those things. Yeah. How do you convince the hospital? Like what was the talk when you were first adopting their solutions? Yeah. Give us those insights. Yeah. I mean, I tell people it's like a, um, uh, it's a constant, you're in a constant state of change management, right? It's change management with legal and compliance. It's change management with the clinical teams. It's change management

[00:29:32] with the care management people is change management. I mean, it is, but that's what I do. Like, I mean, that's like part of who I am and, and, and, and getting people to think about how we do it differently. So the way that, the way that I approached it is like, I was like, this makes sense. Okay. This makes a lot of sense. Um, I went first to the chief physician of the organization.

[00:29:56] Uh, well, my, they had a corporate development on, on my side was my boss at the time. He was like, interested in a partnership. Obviously they're always thinking about how do we partner and do innovative things in that way as well. But we went and talked to the chief physician leaders. There was the, the medical group leader and then the person who was over the system and said, Hey guys, you should hear about this. And it made sense to them. Um, they also understood that it's going to be a little bit of an uphill battle as far as like getting people on board with it and the

[00:30:26] buy-in, you know, there's a process involved, but they said, we endorse this. We will be your sponsor. Okay. We will sponsor this. I think that's really critical to make sure that you have the right sponsorship because what you don't want is going into a system and there's not support, especially at the clinical leadership level, because they've got to help you sell this thing together. And then the next thing, you know, you go through is just a whole lot of diligence to your

[00:30:51] point, the technical diligence, like how, what does the integration look like? What does the lift look like? What are the KPIs and the ROIs that we're going to measure? How do we do the billing? How do we do compliance? How do we make sure there was a lot of conversations around like clinical protocols to your point? Like, how do we know that these people are going to be providing the right care to our patients? Well, we have very specific kind of guardrails within like, Hey, there's pretty clear

[00:31:20] pathways from the ACC AHA. Like there's pretty clear clinical pathways of how to manage these diseases. So how do we translate that into a remote care delivery model, especially when we're talking about titrating medications and then making sure that we listen to the clinicians as well and their feedback. So it has been an iterative process in learning and, you know, making adjustments. I think that's one of the things that I was really impressed about with, with Cadence when I wasn't at Cadence yet,

[00:31:50] was that they were such a good partner and such a good listener to, uh, when we would give feedback, they would take that feedback in and they would be responsive to it and make, you can almost like influence some of the product model through that feedback, uh, mechanism, which I thought was really important and a good sign for a good partner. Um, and then you ask like, well, how'd you get the doctors on board? Not all of them are on board initially. And I tell people,

[00:32:18] I truly believe that remote care delivery will be, um, standard of care. It will be table stakes. It will be something that you will need to do in order to manage your panel of patients, a subset of which is health is aging healthy or has chronic disease burden. You are going to need a delivering system like this, but it takes almost a decade for that transformation to occur. So where do you start?

[00:32:48] You usually start with the very early enthusiastic pioneers, right? The people who like don't care if the workflow is all clunky, they just heart innovation and they want to try anything. Like you start with a couple of those just to kind of test it out. So we found, um, you know, uh, um, health system that I was at with 10,000 clinicians across eight states. I'm sure we can find

[00:33:17] one or two sites where we could, you know, get some willing parties to participate. And that's what we did. We found a couple of sites and then we were very, um, disciplined in the way that we structured the pilot. It had a specific timeline, a number of patients that we wanted to get enrolled, all the things that we were going to measure along the way. And that was done in partnership between the two entities. And then like, kind of like a drop dead date, like, Hey, we're going to get to

[00:33:45] this point. And then we got to make a decision to go from phase one or pipe. Nobody likes to talk about pilots anymore. Phase one to full scale or the next phase and scaling. And so, you know, that's, that's kind of how we managed it. I would say initially it was, um, a lot of push when we were starting to expand. Okay. Who wants to go next? Um, some people would volunteer, some people like

[00:34:12] we would have to, you know, kind of push it. And now I would say there's more of a pull. So it's just an evolution over time. You want to make sure that you have your army of change agents. So you go from your, your, I heart innovation doctors to your early adopters who are like, you know, maybe they're less tech savvy, less interested in having something burdensome. And then you move to the next phase of folks, which is like strong medical leadership at the

[00:34:40] local level, willing to kind of push this, um, to get it scaled across teams. And then eventually the institution needs to make a decision like, Hey, we're going to do this. This is going to be a standard in all of our practices. And that's kind of how it evolved. I would say as more and more health systems pick these types of programs up, which I believe we are going to grow very rapidly. And we are going to be part of the care delivery in many health systems. It's going to become more of a normal

[00:35:09] thing, but it is, it's like you're, you're learning a new skill when you're learning how to kind of manage this as a clinician, whether you're on the delivery side at cadence or you're, you're in the health system. It's a, it's a process. Um, and it's a change management process. And the amount of time that it takes, like I said, it takes years to kind of make that whole shift happen. But I do feel the, the, that we have those headwinds in front of, um, sorry, we have,

[00:35:38] we have a lot of wind pushing us forward, you know, into the future in a positive way. I really feel like, um, we're going to hit a big wave here pretty soon. Wow. Um, a lot of listeners for the show are founders, companies who are selling into health system. And this is kind of a great masterclass that we covered just now, like how to know about, uh, getting into these institutions, uh, you know,

[00:36:05] big health systems, how to get in there and get like, uh, and I always have this, everyone knows it theoretically. Right. And, but it's a very still fundamentally, you need to have these basics, right. And you need to have the person who's there, the champion needs to be that your true champion, that he can help you identify, Oh, you know, these are the really the innovators. So these are the sites

[00:36:30] first for implement and pilot. And that plays a bigger, bigger role. So you just gave this for an internal air traffic controller, and you need an internal stakeholder like mapper. And then you, you absolutely need an executive sponsor with decision-making authority that people respect and

[00:36:54] will listen to. I mean, if you don't have those three things, um, you know, you're just gonna, it's a maze. It's depending on how big the system is too. I mean, some of these systems are extremely large, extremely complex. And the, the thing that does happen, and I know the digital health founders on the call here will know exactly what I mean is that you also have executive turnover,

[00:37:22] right. And so you go all the way down the path with a particular stakeholder who is like awesome and the huge champion. And you're like two weeks away from signing the contract or something like that. And it's like, Oh, by the way, I took a job and I'm going somewhere because you know, executives, they, they move around, they move up the ladder, they find new opportunities. And you're like, Oh no, who's going to carry the torch for me? Um, and I've seen that happen both internally,

[00:37:50] uh, at, at health systems when I worked at them where we've like, you know, taken something so far. And then when they lose their champion, it's like, Oh yeah. So you have to be thinking about all of these things as you're taking risk, expending your reset resources at a startup trying to, to get into a health system. And I also would tell people like, you know, and this is more just for

[00:38:13] like earlier startups, like be really strategic about which health systems you're going to approach with your solution because a very large complex health system will often want a significant amount of customization and they can crush you. I mean, they can, they can absolutely crush you if they're not, uh, tolerant to, you know, depending on what stage your startup is,

[00:38:40] the level of tolerance that they have, um, and their willingness to bend on what they require could really, um, be a disservice to your, your growth trajectory as a startup. So you got to be really thoughtful about where you want to go. And sometimes medium size health systems or smaller health systems are good places to start too. Yeah. Um, something that also you mentioned, I want to rephrase this in, uh, you know, we have passed this phases in healthcare earlier.

[00:39:09] It was all fragmented. Then we went through this phase of consolidation where acquisition and mergers happen. They go into an umbrella of health system and now companies like Cadence, which I would like to say it's more like a plug and play, but not just one tech piece, but it's like a whole operation, tech, everything. It's like a piece of it that can go. So I don't know what's the word I'm just throwing out like almost like a plug and play integrators that goes in, does the job, right?

[00:39:35] And this is the direction we are moving. And if you see, uh, just economics wise, business sense wise, it just so makes sense, right? Like, uh, so I think there is something which is in a good way, the sign that I'm picking happening in the industry is the, the change management. It's happening in a good way that we are now able to take chances and go with this plug and play system.

[00:40:00] There was this rigidity before this, where we will not talk to external things. We will just shut it down. And I think it seems like we are moved to that phase that now everybody's more like, how do we make this work so that we don't have to do like overwork if we can find a partner to work it and more efficiently. And if it works and it also generates more revenue, even better with the outcomes, right?

[00:40:26] Yeah. And I mean, health systems, they do operating rooms, hospital beds, uh, imaging set. They do those things really, really well. They do clinics, you know, brick and mortar clinics really, really well. And they only have a certain amount of resources that they can focus on their core business and their core operations. So how do you start to

[00:40:50] build a digital infrastructure and ecosystem around that so that you can extend your reach beyond what you do in your brick and mortar? And you don't necessarily have to do all of it yourself, right? And we've seen this in other specialties in medicine. It's happened. Maybe it was a technology, but it was definitely care

[00:41:13] delivery, different, uh, ways of organizing care delivery with partnerships and, um, integration. So for example, tele radiology, that's a perfect example. Okay. The radiologists don't want to be up all night reading scans in the E stat scans in the ED. Um, it's hard to find the workforce to do it. So what do they do? They have these tele radiology programs where they contract with folks over in

[00:41:40] Australia and like different parts of Europe. And they do the reads at the night. And so they can get a stat read done. And then in the morning, you know, the, the, the team over reads it. Like that's the perfect example of like, you know, doing something like that. As an OBGYN, one of the things that was very transformational for us that happened at the beginning of 2010s was the rise of the OB hospitalist programs. Used to be you'd have an OB, I had a group

[00:42:11] five OBGYNs. We were on call every fifth night. I just had my second kid. I thought I was going to die because I was so tired. And they said, Hey, we're going to bring in this program where there's an OBGYN in house 24 seven. They, they'll triage your patients. They can help labor them. Like, you know, everybody thought this was such a foreign thing. People threw tomatoes at the CMO when he said he was

[00:42:34] going to do this over my dead body. Will anybody check my patients or deliver my patient? Guess what? It's like standard in any tertiary OB unit. It's not more than a hundred deliveries a month. They have an OB hospitalist program. And, you know, it's a standard thing and it's normal and it's better care. It's safer care. It's been proven. And it gives like, uh, relief to people like me at the time who

[00:43:04] would take, you know, 48 hours of calls sometimes on the weekend at a time completely exhausted. And, you know, you don't want me doing a hysterectomy on your mom, um, the day after I've been on call every night, you know, and, and that's the kind of stuff we were doing. It wasn't, it wasn't a good way to practice and it wasn't wellness wise, a good lifestyle. And so now they've brought these programs in and they are an extension of the OBGYN team. So this is just

[00:43:32] another way of extending the care delivery model. It seems foreign, but it's actually not. If you look at other examples and other specialties across the, um, the healthcare ecosystem, you see these types of innovative models happening in many places and they all have their different periods of evolution that they go through. I think one of the misconceptions that you dissipated today is like a lot of people

[00:44:01] think that when we, when we talk about digital ecosystem to support it, it's just technology thrown at people who are working there. And that becomes like, ah, this is just on things thrown on us, but that's not the case. You have a whole things infrastructure comes with it, logistical support, operation support. This is way more. And if that can happen, that's a game changer, right? Yeah. Why do you think, so you asked me why I, I came to Cadence because, well, it started with,

[00:44:31] um, when, when I brought them in, you know, to the health system that I was at, I truly believe, but when I started seeing them start to scale and the proof points that they were showing from a clinical quality outcomes perspective, reducing the blood pressures, increasing guideline-directed therapy for CHF, getting diabetics in better control. I was like, guys, you've got to do a total

[00:44:55] cost of care analysis. Like I, if, if you can show that you can break even a little bit more on fee for service and then reduce total cost of care. That's like game changing, Holy Grail. So 5,900 patients, total cost of care study that they did, uh, they just completed a couple months ago that showed an average of about $1,300 per year in total cost of care reduction for that,

[00:45:25] in, on average for that patient cohort. This is Medicare patients that we know we need to lower total cost of care. And this is taking into consideration, this includes the cost of the remote patient monitoring program. So it's not like we excluded that. So, so over a thousand dollars savings. Okay. So you win in fee for service, you win in total cost of care or value-based care. These are the types of programs and that the reduction in total cost of care is when,

[00:45:55] is due to a, largely due to a large reduction in admissions, right? Which is like, that's better for everybody. You're preventing strokes, you're preventing CHF exacerbations, like the impact, and just think about it at the individual patient level, right? You prevent a stroke. That is like a life-changing event if you can prevent that with this program. So when that data came out, I was like,

[00:46:21] this is, this is, this is a, so exciting. This is like such a breakthrough to get numbers and data and impact at that scale. And we're doing something that nobody's been able to do. Um, and we're continuing on that journey. And like I said, the goal is a million patients, uh, by the end of this decade. And, and I think we are on a great trajectory to get there. Wow. Yeah. Um, before I conclude today's

[00:46:50] conversation, last two questions for you, one, a fun one and one, a little futuristic, how you view the world, because, uh, I'm, I'm really impressed with how you view the tech and in general, everything around it to the outcome. So if you have to predict the biggest change in healthcare over the next five years, um, I mean, you're already on the remote patient monitoring, but what's the next, what,

[00:47:16] what do you think what it would be in the next five years? Yeah. So remote care delivery is going to be a standard of care, right? Being able to meet patients in their homes, that's going to be a standard of care. So that's on the care delivery side as it pertains to, uh, clinicians. If you are

[00:47:36] not embracing AI, playing with AI, using AI, you're going to become obsolete. Um, there is just no way we are going to be able to function effectively as clinicians without leveraging tools that with, with, with AI. And so I truly believe that that integration of augmenting our clinician workforce

[00:48:03] with AI is, is the next big thing. And you're already kind of seeing that happen with, uh, some of the things that are just people are starting to adopt like open evidence, but it's going to go beyond that as well. We need co-pilots to help us make good decisions. We really do. Yeah. Yeah. I mean, um, we've already seen huge impact in tech industry and, uh, it's like we used to say, and again, I also have an engineering background for us, 10 years. I was a software engineer for

[00:48:33] Verizon, Oracle, big companies. And, uh, I remember that during those days we used to have like, oh, you know, they're in engineering, they were tasks. Like they were like super good engineers who will build modules and solve complex problems, but also there was still room for engineers who were not that skilled, but they were really good in handling the maintenance tasks. Right. And those were really important to maintain IT infrastructure and everything. And as soon as this AI thing came,

[00:49:01] those are the tasks wiped completely off. And, and, uh, this has, this is already happening or happened. 70% tech jobs are gone from indeed. And all these, this is the latest reporting. Um, this wave is now entering this year to other areas, other functions, other industries. And, uh,

[00:49:24] and I think this is going to hit healthcare really big, really soon, not to scare anyone off, but, uh, but it is, uh, it is because just, it supports the work much better with a lot of, we have so much data, so much, uh, administrative work and so many things to support the actual care delivery and so much things happen. So those things are going to be very, very critical. And this is why to your point

[00:49:48] that it is super important for clinicians to start getting their hands dirty in whichever way to just understand how can each clinician has almost like their own agents to do the work. Right. It's true. And there's a whole like community of us that are, I mean, like Graham Walker, Spencer Dorn, Sarah Gabow, or like, there's a whole group of them that, you know, we see on social media and

[00:50:13] things like that, where you see people building POCs, experimenting with things. And it's, it's great because I think people need to pay attention. But what I realize is a lot of like the just boots on the ground, um, clinicians who are just grinding through the day. They're not aware to some degree of what is happening. And, um, and so I encourage people to experiment with it, to mess with it, to learn how

[00:50:41] to prompt, you know, and get, you know, cause I hear, well, I prompted it and I didn't get anything. And I'm like, well, you need to be more specific. You need to refine, you need to almost act like you're talking to a medical student and see what she can get out of it. Um, because it is quite fascinating. And I do think that it's very important for clinicians to be involved in the design and development and validation of these solutions. Um, critical for a number of different reasons,

[00:51:08] as you know, but I do think, I don't think doctors are going away. I just think our work is going to change. Um, and there's going to be ways that it's going to change in a very positive way because we're cognitively trying to process so many things from so many different sources, from a data information knowledge perspective to now have a technology that can help us process that much

[00:51:33] faster so that we can actually spend more time with the patient doing the things that matter most to them. I think that that's, that's, that's going to be a beautiful thing for, for medicine. Yep. Well, this has been great. My last and final fun question to end our conversation today. Uh, so tell us one thing that no one in your professional circles

[00:51:57] knows about it. And this is your chance to tell the world what it would be, could be anything that you would like to share. And, uh, people give many examples. Sometimes it's a hobby. Sometimes it's a secret that they were told. Sometimes they were like, Oh, I also do this thing. Do you know that? So it's all up to you. Tell me about it. Oh my gosh. I don't know. I thought about a couple

[00:52:23] different things. I'm like, should it be spicy or vanilla? Um, okay. Like here's something really embarrassing. Uh, when I was like 12 years old, I had this thing, 12, 13 years old. I had this thing for like dying my hair, different colors. So I dyed my hair red, I had braces. And for some reason I grew up in Tucson. So I don't know if you've ever heard of Lisa Frank, but Lisa Frank is like this,

[00:52:47] like, um, kids, like backpack, uh, like folders, notebook, pencil company that has like these really, uh, animated decorations on them. And I got discovered to be a model on Lisa Frank. Cause they wanted somebody with red hair and braces. So I actually had a very short stint as a Lisa Frank

[00:53:13] model. And I got to be in advertisements in Barbie magazine, Sesame street, and some others. And, and if you look really, really hard, you might be able to find one of those friends, but you may not recognize me because I had red hair. She called me back like five months later to do another shoot. My braces were gone. My hair was brown. And she's like, who are you?

[00:53:39] It became a big thing. Lisa Frank being a model for Lisa Frank. It was like in the early stages of Lisa Frank. So then it became like this big, like search thing that they did in Tucson at the time. It was like some, I don't know, it was walking down the street and randomly it was at the mall or something. And they asked me to, to do this. Wow. That's a fun story. So not only became a model and then they tried to find you again, they were like, what happened? They ended up taking pictures

[00:54:07] of me. And then they said they made a life-size version of me for some trade show, which I've never been able to see it. Like fascinating. See, that's a great, uh, great share. Thanks. Thanks for sharing. Well, uh, this has been great. Thank you so much. Um, now, if, uh, people want to get in touch with you, how can they get and reach out to you? Well, they can reach out to me the easiest way. It's through

[00:54:34] LinkedIn. I would say that's probably the best way to connect with me. Yeah. All right. We will also put the link in whenever you get the show so you can connect, uh, with Dr. Geningham. So this has been great. Thank you so much, much appreciated. Uh, this has been great conversation filled with lots of insights and we also learned about, uh, cadence. And I actually think that, uh, my total understanding was slightly different. And after this, I feel like, wow, oh, this is going to be great. So

[00:55:03] I'm excited about it. And, uh, um, I know cadence is also a unicorn. So that's kind of, they hit their evaluation 1 billion plus. So that's great. And no doubt why it is doing that. Now it makes sense to me. I was like, okay, you know, this is this kind of- We are very unique in the market. It is our,

[00:55:24] definitely this is, um, we are in a great position and, um, amazing team. The CEO is a good friend and just the best. And I just, I'm so thrilled to be, to be on this ride with them. Yeah. All right. We will also post link to cadence and how you can find their website and discover more about them. And once again, thank you so much. We appreciate you. Thank you. Thank you.