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In today’s AMA Update, Arash Harzand, MD, MBA, senior innovation fellow at the VA Office of Healthcare Innovation and Learning in Atlanta, talks about digital transformation in health care and how it’s helping to fill critical gaps. AMA Chief Experience Officer Todd Unger hosts.

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Speaker

  • Arash Harzand, MD, MBA, senior innovation fellow, VA Office of Healthcare Innovation and Learning

AMA Recovery Plan for America’s Physicians

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Unger: Hello and welcome to the AMA Update video and podcast. Today we're talking about digital transformation in health care and how it's helping to fill critical gaps. I'm joined today by Dr. Arash Harzand, senior innovation fellow at the VA Office of Healthcare Innovation and Learning in Atlanta.

I'm Todd Unger, AMA's chief experience officer in Chicago. Welcome, Dr. Harzand. How are you today?

Dr. Harzand: Very good. Thanks for having me.

Unger: Of course. You're with the Veterans Health Administration. It's the largest integrated health care system in the country. Why don't we just start? Before we dive in, give us a little bit of background about who the VA serves and how their needs are unique.

Dr. Harzand: Yeah. I mean, I think the VA has a system really focuses on our really special population. As a defined sort of patient cohort, U.S. veterans are pretty unique in a lot of ways. I think one of the ways that we really try and emphasize veterans at the outset is in a lot of ways they're not unlike non-veterans in terms of the kind of problems they have as patients, which is I think important for us to always keep track of. But they do have special needs, some medical, some social, some economic.

And on the medical side, we know about mental health being a primary driver of what's in the news, PTSD and traumatic brain injury, suicide. About 20 veterans a day commit suicide. But medically, I think veterans are also at a high risk of heart disease more than non-veterans.

So veterans are more than twice as likely to develop ischemic heart disease as non-veterans. As a cardiologist, that's one thing that I sort of really kind of focus on. But on the flip side, on the non medical side, there's a lot of other issues as well.

There's high unemployment. A lot of veterans are mostly on fixed incomes, a high degree homelessness in a lot of rural veterans as well. So really, we have to both target the common things and focus on the common things that most patients need but also some of these very special unique aspects of the veteran population.

Unger: So with that kind of context in mind, talk about the role of innovation and how it's been critical to the VA in terms of providing high-value care and meeting the needs of this particular population.

Dr. Harzand: Yeah, that's a great question. As an integrated system, the VA really has no choice but to innovate if it's going to meet its needs. There's no blueprint to how you run and extract value in a system as large and as complex as ours. So you have to innovate from the inside.

The VA is one of these interesting places that is probably one of the earliest but in a lot of ways one of the kind of latest adopters of digital technology. We sort of were one of the first to build EMR, one of the first to really engage in telehealth, but we've been slow I think the past decade when it comes to embracing the cloud and really diving in deep in digital health. And so we're kind of playing catch up.

But for us, the need to innovate really is not just—a lot of organizations have an office of innovation. We have one as well but really innovation as a culture is not an office. And for us, that's been a core part of the mission because there's no other option to meet the needs. We have to find new and novel ways of meeting veteran needs and extracting as much value from the system as we can.

Unger: It's interesting to think about the juxtaposition that you've talked about there between being early adopters in certain technologies and later on others. When you think about the path that you've taken at the VA, how does this map to perhaps a model for other physicians?

Dr. Harzand: Yeah, that's another great question. I think the VA like every other health care system is big and complex, and change doesn't often happen very fast. And so the VA in a lot of ways kind of—we showed up. We sort of dove in head deep on a number of areas, that we slowly kept on incubating and proving incrementally. And now fast forward about a decade or more, we're in this sort of sprint to really kind of get up to speed.

And even that I think is similar to a lot of other systems that have a lot of legacy solutions that they're using. And physicians really have always kind of helped propel health care systems forward because we're the ones that really use a lot of the technology alongside the rest of the care team and the nursing staff, and everybody else.

And so I think, as an individual, what I've been trying to do here in the VA locally and then nationally is—we're all fighting the same battles. And I think the way I would kind of phrase it to people is to say, well, look, if we can do anything on a scale significant in a system like the VA, which has so much potential but also so large and bureaucratic, right, there's no reason why you can't do this somewhere else. And so it's hard to give specific guidance to people in different environments but I think if you're persistent and you know how to be problem focused, which I think is one of the key areas which is—you don't want to basically be an innovation looking for a solution.

You really want to be a solution-driven, problem-focused culture that is building things and adopting things with a specific purpose and goal in mind that you can then measure, not just the shiny object, which all of us are guilty of, especially physicians. And I'm a cardiologist by training. We have more toys and tools then we know what to do with.

And just because it's expensive and new, as we all know, that doesn't translate to value. In most cases, it translates just to more cost. So we have to be really intentional in what we focus on and what we adopt. And I think it, like I said, goes back to being as sort of problem focused and mission driven as we can be.

Unger: Would you say that kind of intentionality and that kind of problem-solution focus is the big piece of advice you would give others that are undergoing digital transformation like this?

Dr. Harzand: I think so, yeah. I mean, I think on the one hand, you have to sort of build the infrastructure. And so you have to think of the problem in a grand scale. We have a large issue with access, for example, right. But once you get into the—when you're looking for solutions that you're implementing for specific either conditions, or disease states or specific patient problems, you really have to drill down and be mission focused.

And one thing I've had to adopt and learn to adopt the hard way is to sort of walk or the crawl, walk, run because all of us want to just start running, right. And we're sort of bred like that. As clinicians, we're in training for decades or more.

You kind of like show up, and you want to just like do something, right. And we have a lot of that potential but we have to really start small to demonstrate the feasibility and the need before you can start to scale. So that's a big part of what I do and what we learn to do in the VA.

Unger: And I'm sure you've learned that the kind of innovation is not just a matter of technology. There are a lot of things that have to catch up with that in terms of systems that's around that. And to that end, let's talk a little bit about telehealth. That is an important pillar of AMA's Recovery Plan for America's Physicians. This is, obviously, something that exploded during the pandemic.

And now we're working to support it long term as a really critical part of integrated care. What new and innovative care delivery models do you see emerging right now? And where do you see the greatest opportunity to use digital health tools, like telehealth, to improve patient care?

Dr. Harzand: Yeah, I mean, it's interesting. I think on the one hand, we're in a situation where we need to find and adopt solutions for the here and now. I think all of us are to some degree putting out some fires.

So a lot of it is just the kind of basics. It's even sort of setting up a system where you can provide seamless video visits to your patients, not very easy. And even for the VA, in a pandemic, early in the pandemic, we had already implemented a system for video visits called VVC. And we have to scale that from about, I think, it was 10,000 visits a week nationwide to over 90,000 in the matter of a month. And we didn't have the infrastructure to do that seamlessly.

We did it. But like you were saying, we sort of were out ahead of what the system could sort of support, not just from a technology perspective. We had the systems and the cloud capability to support the scale.

You have to get the staffing and the support structure, and the providers, all on the same page. And you can't do that. It's harder to do that in retrospect.

Now, COVID was sort of a special case but I think that's a sort of bellwether I think for—or should be a bellwether for the rest of us, which is you have to think ahead. So a lot of what we're doing so far is the focus on that. A lot of what I'm focusing on—sort of the moonshots—are things really focused on patient-generated data.

We're in a situation now where patients and veterans are using a lot of devices in their own lives. They want to share some of that data with the health care system. They want to use some of that data as part of their care plan. When they come and see me and I say, hey, we should have wear this Holter monitor and then the patient with the Apple Watch says, why? I've got this Apple Watch. I can tell it can do an EKG, right.

You can have the conversation and you should. And just to be clear, I'm not trying to say that an Apple Watch can meet the needs of a diagnostic device but you have to recognize that patients are using these tools in their lives. And so there might be some value there.

And so you have to find ways to let them engage with us using a lot of their own devices. And that's a lot of what I've been focusing on in digital health in the VA is kind of building that infrastructure to at least test and evaluate early stage what's some of that integration and data sharing kind of looks like. There's other stuff that we're doing that I think sort of is more in the kind of moonshot category.

So we have a very large network for augmented reality. So we have 130 sites doing AR and VR for a variety of applications, primarily pain management. And we do a lot during procedures. We have veterans wear AR headsets to guide them through what's going on and keep them relaxed and address some of the stress and anxiety.

We've done a lot with 3D printing. And that's been a big part of our evolution the past couple of years. And one of my colleagues, Beth Ripley, who's a radiologist out of Seattle, has kind of led that for us nationally.

So I mean, I think there's a lot of edge cases like that but it's really easy to just focus on the edge cases and forget what the edge cases are on the edge of, which is the core of what you have to deliver on a daily basis. So that's I think the struggle for innovating in telehealth. You have to do both.

Unger: Well, you've been working in collaboration with the AMA to put together a lot of resources. Maybe for that kind of—the bulk of change, can you talk about the collaboration what kind of resources you're working on?

Dr. Harzand: Yeah. So we've been really excited for the past couple of years to work with a number of groups. So DiMe, the Digital Medicine Society, and by extension groups, like the AMA, that DiMe has sort of brought in to our orb more closely, to really think about not just what the VA is doing internally and how we can do it better in the arena of digital health but how can we really engage and partner outside of our walls? Because oftentimes, there's not many people who get really excited about partnering with VA and the government.

They love the mission. They love the scale but the nitty gritty and the daily grind of it all can really be taxing. So you have to work on as an organization breaking those barriers down. And we have to go out and engage directly. That's on us.

And so one of the resources that we've just published along with DiMe and AMA, and other partners, is what's called The Playbook, The Digital Health Care Edition. It's sort of piggybacks off of DiMe's initial Playbook for Digital Biomarkers.

And so this is really focused on digital health care tools. And it's published online on the DiMe website. And it's free for the public. And we could talk about what's inside there but that's really kind of so far been the first kind of foray into us really trying to embrace the world, the digital world that's sort of evolving and growing outside of our walls.

Unger: Now, I know we talked a little bit about the technology part and about the people part. And one thing I like is one of your focus is on asking physicians to share success stories related to the digital transformation. Is there one you'd like to close this segment off with that speaks to the transformation you're going through?

Dr. Harzand: Yeah, I mean, I think one of the—again, this is trying to focus specifically on one area. But one thing we're really excited about is a really cool collaboration, really a cool initiative focused on ending diabetic limb loss amongst veterans. That kind of embodies all of that, where we've had to build a system for outpatient screening and early identification of diabetic ulcers. And we're doing that with a technology for thermography in partnership with a company called CodaMetrix.

And so now we're deploying their thermal maps to veterans who are at high risk for having ulcers and possible limb loss. And then we've been working diligently to sort of pair that with the existing care pathway we have for screening for diabetic foot ulcers that already exist in the VA and working to connect all the pipes and really make it as seamless as possible so veterans get up in the morning, they step on their map, stand there for about a minute, that data transmits to the VA. And then if they hear nothing from us, then that's fine. Otherwise, if we get an alert or if there's anything concerning, we actively reach out to them and bring them back in. And so that's one I think very focused area that we're really excited about.

We've deployed this at a number of sites across the VA. We have some exciting internal numbers on the performance of this. And some of that's been published.

Some of that I think is going to still be published but we're really excited about that type of work that, really, seamlessly places some digital solution in the life of a veteran and a care team and enhances it and doesn't add more to it and really delivers value back to the veteran, because otherwise that veteran will be coming into the VA to get that same scan done. And now they can do it from home. So that's immediate value back to the veteran and even a very small way but a very significant way.

Unger: That's a great story. I think people are probably going to be surprised out there, the amount of innovation going on at the VA. It's really interesting and, obviously, with the size of the system, going to have a huge impact on health care going forward.

Thank you so much, Dr. Harzand, for being here today. That wraps up today's episode. We've included a link to the VA's Playbook, as well as a number of other helpful AMA resources, like our Return On Health Virtual Care Framework in this episode description. And you can learn more about the AMA's efforts to support telehealth as part of the integrated care at ama-assn.org/recovery. That's for the AMA's Recovery Plan for America's Physicians.

We'll be back soon with another segment. In the meantime, you can find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. 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.

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