Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.
In today’s COVID-19 Update, Shantanu Nundy, MD, MBA, chief medical officer at Accolade, as well as a physician, entrepreneur and technologist proposes a post pandemic framework that looks to have health care distributed (meets patients where they are), is digitally enabled and decentralized. Dr. Nundy also shares ideas from his forthcoming book, "Care after COVID," and the central role of physicians in leading the change ahead.
Learn more at the AMA COVID-19 resource center.
- Shantanu Nundy, MD, MBA, chief medical officer, Accolade; primary care physician and author
Unger: Hello, this is the American Medical Association's COVID-19 Update. Today, we're talking to Dr. Shantanu Nundy, chief medical officer at Accolade and senior advisor to the World Bank. Dr. Nundy is also a primary care physician internist in a safety net clinic in Washington, D.C. and the author of a forthcoming book called Care After COVID. He'll be discussing a new framework that he's developed for health care post-pandemic and the central role of the physician in leading the change ahead. I'm Todd Unger, AMA's chief experience officer, here in Chicago. Welcome, Dr. Nundy. I'm excited to learn more about your book and your framework. Why don't you start by telling us how you initially got thinking about this new framework for health care post-COVID?
Dr. Nundy: Yeah. Well, Todd, so great to be here and have a chance to chat with you. I didn't plan on writing a book or developing a framework. A month into the pandemic, when, if you remember, everyone was talking about testing, testing, testing, where can we get tested, I had a really simple idea, as a lot of doctors do who are on the front lines. I said, what if patients could test themselves and do it at home? And so that's really what started me on this journey. I asked the question. I wrote an op-ed, it went viral. People were really interested in the idea, but policymakers didn't get it. And that's when I realized we needed a way to sort of shift their mindset, and that's the whole genesis of the framework.
Unger: You work in kind of a safety net clinic. How did that inform your perspective and understanding and create this vision for the future?
Dr. Nundy: Yeah, absolutely. I mean, I get most of my ideas from clinic. I think the framework's really simple. It's we believe that health care needs to become distributed, digitally enabled and decentralized. And so when I think about my clinic, when I think about distributed, it's we need to meet patients where they are. Coming to my clinic isn't the easiest thing in the world for my safety net patients. They've got to take a half day off of work and find an appointment, find someone to take care of their kids and wait in a waiting room.
And so distributed is just, hey, can we use virtual? Can we use home-based care to meet them where they are? Digitally enabled, so what I noticed is a lot of my patients, they have a hard time making it to appointments, taking their medications, learning about their conditions, but they're always texting each other. And so can we use new, simple technologies like messaging to connect with our patients between visits, so it's more continuous and easier to get to?
And then decentralized is this idea of just giving doctors at the front lines and nurses more resources. I remember this patient I had, who was in and out of the hospital with heart failure, and patients with heart failure, they need to check their weight every day. And I just asked her, I said, "Do you have a weighing machine?" And she was very shy to say, "No, I don't." And so I just handed her 20 bucks out of my wallet and realized that we can pay for a $10,000 hospital visit for her, but we can't give someone 10 or 20 bucks to get a weighing machine. And so that's what I mean by decentralized.
Unger: Yeah, that's so important. In fact, I have my 86 year-old mother visiting this week and talking about her blood pressure, and I brought out my home blood pressure monitoring device and measured it right there. These challenges that you bring up in your kind of three Ds, which you're saying basically it's distributed, digitally enabled and decentralized, that's a great vision for where we need to go. And obviously there are going to be a lot of challenges in this. I mean, for one thing, we just went from zero to a hundred miles an hour in terms of telehealth. And there are a lot of issues in that and not just the infrastructure and technology part of it. Can you talk about, just let's focus on that part, the digitally enabled part, what are going to be the obstacles there to seeing that brought to life?
Dr. Nundy: Yeah, it's a great question. And there's going to be no shortage of obstacles, right? I mean, I think the first is we know that not everyone is wired up. So whether that's you live in a place that don't have bandwidth, you don't have a connected device, or you don't have the digital literacy to be able to use those tools. I think that's a huge challenge for us to make health care much more equitable and inclusive.
I think the second challenge is really workflow. I think every doctor understands our workflows, and really figuring out how to integrate that into our workflows, that we can seamlessly go between a patient that needs to be seen in an office, because that's not going to go away, to a patient who needs to be seen virtually. And how do we sort of shift between those two very different worlds?
But I think the biggest one that we're not talking about is the fact that we don't want to just take a health care experience that may not get the outcomes we want that's in person and move to a health care experience that may not get us the outcomes we want in a virtual world. And that was the mistake we made with medical records. Every doctor knows that experience of, okay, you took a paper chart and you basically scanned it on a hundred million dollar piece of software. But you didn't make the documentation process better.
What we need to do is take digital and actually change the way that we care for patients. Rather than like, for someone with diabetes, it's not let's see them today and then in three months and in three months and hope that they're going to eat the right things and do the right things. It's how do we actually start meeting them where they are on a more daily or weekly basis, so that we're giving them those little nudges and that little education they need to actually change their daily behaviors.
Unger: So that's real digital transformation of the patient experience and care, as opposed to, what you said, like with an EHR and just transferring one not very ideal situation into something that you can do on the computer. So how do you push forward with something like this? I'm encouraged, for instance, that broadband is part of this infrastructure initiative that we're seeing kind of percolating right now. What are the other things that are going to have to happen for this to move ahead?
Dr. Nundy: I think a huge part of this is about leadership, and really, I think physician leadership. An example I give is this, during the pandemic, my mom, who has type two diabetes and has had it for 25 years, been on insulin for 15 years, she completely got off of insulin in a month. And she did that because she kept hearing about if you have diabetes, COVID is worse, COVID's worse. And she signed up for this digital service that does this program called diabetes reversal. And what it does is it helps patients get on a ketogenic diet. It gives you a doctor who will help you titrate down your medications. You get a nutritionist, you get a coach, you get a peer.
So for my mom, who's from India and eats a lot of Indian food, they connected her with another reversal patient in Chicago, who is also from India and also vegetarian, to help her with her diet. So this is an example of the type of transformation, Todd, that I talk about, which is we didn't just say, okay, my mom has an in-person diabetes doctor. Now let's get her a virtual diabetes doctor. We reimagined the entire experience to say, what are all the things that a patient who wants to go on this journey and potentially find a better way to manage their care, what are all the things that person needs and how can technology make that simpler? Connecting with that gentleman in Chicago was a lot easier with technology,. That's what we need. I think we need a lot more of those proof points. And then we need physicians to really advocate for that level of transformation.
Unger: You know, that's interesting, because a big initiative at the AMA is around hypertension and self-monitoring blood pressure is a big, big initiative. And it has to encompass all those things that you talked about right there, which not the least is having the right equipment at home to be able to do that, and then the infrastructure to be able to communicate on an ongoing basis with your physician and health system so that progress can be monitored. Well, let's talk a little bit more about the role that physicians play in implementing this type of change. What can a physician do?
Dr. Nundy: It's a great question, and it's definitely very bespoke. I mean, that's kind of my whole idea of decentralized, is I think you know your population, you know what your clinic capabilities are, you know your specialty and using all that, how do you bring these kind of creative solutions to bear on the front lines? And I think a great example is the types of stuff we did during the pandemic. I mean, look, the fact that we offer drive-through testing is an example. There is no regulation needed for that.
For years, clinics like mine have had to figure out how to test people for the flu every fall. And every fall, we have sick people waiting inside the waiting room, where they're coughing and sneezing at each other, just to see us for a few minutes so we can do a rapid test. And now we moved that to the parking lot, and there was no regulation needed for that. We have the power to do that. And I hope what I'm seeing across the country, as I talk to doctors, is in many respects, doctors built a muscle over the past year that we didn't really have. We've actually created an entire generation of doctors who kind of think public health and now have operational experience doing that.
And so what I'm saying is let's take that muscle and let's start applying it to diabetes. Let's start applying it to mental health. Let's start applying it for folks that are specialists out there, the things that they're working on. So much more is possible, and I think we've gotten as a profession, we've actually gotten a lot more toolkits and tools under our belts now.
Unger: I love that. I mean, I love your referring to that as kind of a new muscle or new capability that has occurred over the course of the pandemic. I know, just thinking about my team and the same things that we've gone through, after this pandemic, people talk about going back to normal. Well, I don't want to go back to the way it was before, because there are a lot of things that we've done that work better, that are more fair. The access is better. And I think that's what you're really getting at, is let's use this new muscle and we don't need to return to the way things were exactly before.
Well, let's talk about your book. That's exciting. It's coming out in early May, on May 4th. What do you hope that physicians and other readers take away from what you've written?
Dr. Nundy: Yeah, no, I spent a lot of time thinking about that question, because for me, I don't need another job. I mean, I did this, so many physicians I think have stepped up in the past year. You see physicians on TV, physicians helping to lead in their communities. And for me, I really thought hard about what I wanted to do. And for me, I think more than anything else is it's creating that mindset shift. I think there's a lot of people talking about virtual, a lot of people talking about home-based, but I purposely said, well, I think the right word is distributed.
And why? Because it's not like all care is virtual. I mean, even for patients who had COVID, someone still had to stick a Q-tip in someone's nose. That's a very physical thing. Someone still had to fill a medicine. Someone still had to swallow that medicine. And so saying virtual I think is not doing us, I think, thinking about the full episode of care and saying, well, distribute it. Similarly, a lot of physicians have been hearing AI, AI, AI and AI is going to replace your job, and the EHR is the technology that we most know and don't love. Digitally enabled, I purposely said, I said, well, what are you digitally enabling? Well, you're digitally enabling the doctor-patient relationship.
And then finally, the word decentralized, a lot of us are hearing value-based care, population health, but you can't just hand doctors the financial risk of their patients and say, "Okay, well, good luck with that." What you need to do, I believe, is decentralize. Give them more resources, more authority. Simple things. My nurses can't go to someone's house today and draw their blood at home. There's just so much regulation for things that don't need to be there.
And so my hope is that by creating this new vocabulary that what we're going to do is help people shift their mindset and then make decisions on their own. I don't have all the answers, but that mindset shift will allow physicians and other leaders at the front lines to be able to make those right decisions.
We talked about how things get hard, right? So for example, you know, you say, "Oh, well, digital, not everyone has access to this," et cetera. I worry without the right framework, people will say, "Well, that means we should just pull back," versus saying, "Well, how do we actually make digital work?" And I think that's what I'm trying to help people make those kinds of investment and decisions.
Unger: That makes so much sense. I mean, in my own kind of journey in terms of digital transformation, so much of what is key is setting out the vision for where it is that you want to get to and then just laying out the steps so that people aren't stopped in their tracks. I think when you talk about digital transformation, it's sometimes kind of intimidating, but I think the way that your book lays it out in terms of those three "D,"s, we can see those are not out of reach, for us to get where we want to be.
Well, let me ask you one more question. We touched a little bit on it in terms of the digitally enabled part and access. We've seen a real challenge to equity, and you are one of 11 external advisors working with AMA on its equity and innovation strategy through our Center for Health Equity. Can you talk about that work and why it's so important right now?
Dr. Nundy: Yeah, no, thank you for bringing that up. And it's an amazing initiative of the AMA. I think the AMA's really stepping forward in talking about issues like structural racism and all the challenges that we have and the inequities that we've seen. And I think it is critical. I mean, this idea that innovation's always been in medicine, I think sometimes people forget that. Doctors are really innovative. We're always trying to read the latest articles and study the latest things.
But I think what we're doing now is saying ... but innovation and equity, they're not two different things. They're actually the same thing. Because what we want to do, all doctors want is we want to improve outcomes, and what patients want are better outcomes. But when we talk about outcomes, whose outcomes are we talking about? And I think saying outcomes and equity, innovation and equity, are going to become synonymous, but then how do you do that work?
And that's what this center I think is trying to do, is say, this isn't a one and done, this isn't a single article or a single moment. When you talk about something being structural, it is structural, which means you've got to understand the macro, the meso, the micro involved with that. You've got to find those places, whether it's let's get more diversity in who's making these decisions, let's get more diversity in terms of board representation, all the way down to let's have solutions that we know disproportionately are better for patients.
So for example, I mentioned text messaging earlier. Actually, more low-income patients use text messaging than middle- or high-income patients. And that's because for them, it's a necessity. For us, it's a luxury. And so building solutions using something like text messaging is actually one of those rare things that doesn't just lift all boats. It actually lifts those that are most vulnerable more than it does those who are less vulnerable. And so that's really what this is about.
Unger: I'm interested just to hear maybe a couple other examples, because something you said is you're really focused on outcomes and for whom. Because I think if the for whom part is not kind of built into that equation, there are things that can get skipped in innovation and entire populations that can be overlooked. Is there anything that you've seen in your journey thus far where taking that different lens in terms of equity affects the direction of innovation?
Dr. Nundy: Yeah. I think my probably best example is the work that I've seen at the World Bank, where we've scaled community health worker programs, this idea that you can train sort of lay people who are from the community to do basic education, triage. I mean, I think that's the kind of solution that we know works best in the most vulnerable communities. And one that, you know, one word we didn't talk about today yet, Todd, is the word trust. We talk about innovation, but one of my mentors said, "Shantanu, I know you want to innovate, but medicine moves at the speed of trust. And so you want to create change fast, but what about trust?"
And so community health workers are a great example of they already have the trust of the patients we're trying to reach. So how do we then leverage that existing trust to be able to then get to the health outcomes we're trying to get to?
Unger: Indeed, innovation does move at the speed of trust. And I think we're seeing that in this pandemic more than ever. I'm so excited by what this book is going to say. I can't wait to read it and talk to you more about it. Thank you so much, Dr. Nundy, for being on the COVID-19 Update today.
That's it for today's segment. We'll be back with another segment shortly. In the meantime, for resources on COVID-19, visit ama-assn.org/COVID-19. Thanks for joining us. Please take care.
Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.