Return on Health part 1: Teleneurology and telestroke services


AMA STEPS Forward® podcast

Return on Health Part 1: Teleneurology and Telestroke Services

Dec 2, 2023

In 2021, the AMA, in collaboration with Manatt Health, released case studies featuring organizations that are measuring the value of their virtual care programs as part of the Return on Health Framework. Two years later, we’re checking in on their progress.

On this episode, Lee Schwamm, MD, of Massachusetts General Hospital describes how their teleneurology and telestroke services have improved patient retention, preserved inpatient capacity for patients with higher acuity, and more.  


  • Lee Schwamm, MD, Massachusetts General Hospital  


  • Stacy Lloyd, MPH, director of digital health and operations, American Medical Association 

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Lloyd: Welcome back to the STEPS Forward® podcast. My name is Stacy Lloyd and I’m the director of digital health here at the AMA. I’ll be your host for the next few episodes where we’ll be talking with various health systems on how they are measuring the value of virtual care programs within their organizations.

In 2021, the AMA, in collaboration with Manatt Health, launched the Return on Health framework that was created to help organizations better understand the various ways value can be generated through virtual care programs. The framework includes looking at value beyond just the financials, but rather more holistically across clinical outcomes, access to care, patient and family, and clinician experience, financial impact, and health equity. To bring the framework to life, we collaborated with various health organizations to gather case studies on their virtual care programs to better understand how they’re measuring value.

So two years later we are checking in on the progress. We’re kicking off the series with Massachusetts General Hospital’s telestroke program and we’re joined by Dr. Lee Schwamm, a practicing neurologist, former director for the Center for Telehealth at Mass General Brigham, and now in a new role serving as chief digital health officer and associate dean, digital health strategy and transformation at Yale New Haven Health System and Yale School of Medicine. We worked with Dr. Schwamm on the original case study back in 2021 and we’re excited to have him here to give us an update. So welcome, Dr. Schwamm, thank you for joining us, and congrats on your new role.

Dr. Schwamm: Oh, thanks Stacy so much, and it’s a pleasure to be back with you and think about the impact of the framework that was built back then, and how it can serve us as a roadmap in many ways as we move forward.

Lloyd: So to get us started, would you mind setting the stage for our audience and tell us a little bit about Massachusetts General Hospital, Massachusetts General Brigham, of the existing digital medicine and innovation efforts you’re working on there, and specifically touch on the telestroke program that we featured in the report.

Dr. Schwamm: Sure. So Mass General Hospital is a large academic medical center as part of the Harvard Medical School system. We also have a sister hospital, the Brigham Women’s Hospital, also a flagship AMC in that system. And together the two of them, along with a large number of community hospitals and community-based practices make up the Mass General Brigham Health System—formerly known as Partners HealthCare—which delivers an integrated care model across the state of Massachusetts up into New Hampshire and some of the adjacent New England states, and is also a regional and international referral center.

One of the earliest forays into digital health at Mass General Hospital and in the system was our TELSTRO program. And in fact, if you look at the expansion of our health network and the hospitals that went from affiliations to actually becoming fully owned and operated by our health system, every single one of them had a telestroke program first.

And it was a really interesting way of demonstrating the value with a capital V, not just the financial savings, but the value of a deeply personal relationship with another hospital where members of that hospital staff were available and delivering care on demand 24/7 in an environment of significant need, which in this case, was the emergency room or the ICU for patients who are experiencing an acute ischemic stroke. And that philosophy I think has always been front and center in our digital programs, but particularly in the telestroke and then teleneurology programs, which is what is the clinical problem we are trying to solve for? And where can we find a space where the digital is actually synergistically better than the alternative? Not just a second-class replacement, but actually improves, increases the value, the experience of the patient, the timeliness of the care, the clinical outcomes, because that’s where you see real value creation.

Substituting one for another hybrid versus in-person is I think a sort of false dichotomy and we have to get past that in our efforts to really bring a digital enablement to health care. So the program began in its pilot phases back in 1996, ‘97 when TPA, also known as Alteplase was first approved as a treatment for stroke. And we had lots of regional hospitals calling us to say, “Help, I don’t know if the patient’s having a stroke, I don’t know if the scan is okay, but should I treat them with this new drug?” And we would be like, “I can’t really answer that because I got to see the patient, see the scan, examine them, explain the risks, then we could recommend treatment.” And we quickly realized that with the advances in the internet and video compression technology and portable video becoming increasingly available, that we actually had a platform that we could leverage.

So we built that out over time and things took a ... first site was Martha’s Vineyard Hospital 2001. Then in 2005 we went statewide as the state introduced policy and legislative requirements that hospitals that were going to treat acute ischemic strokes and receive them by ambulance had to essentially attest to having the right equipment, the right personnel, and the right expertise available 24/7. And we became an immediate solution for that. And we now partner with about 30 hospitals, mostly in New England, some within our network, some outside our network and several in other states. We’ve franchised the management model. So some hospitals partner with us to use our platform to render care in their own networks. Others leverage our staff completely and some do a hybrid of the two. So again, really trying to solve the clinical problem, not just have a cookie cutter that fits for everybody.

And in the beginning, most of the patients we treated either with consultation or with the TPA, the clot buster medicine, were all transferred in to one of our two hubs in our academic flagship hospitals. No one was comfortable caring for and treating those patients. Over time, by infusing quality upstream through these digital channels where building capacity in these smaller community hospitals, they become more and more comfortable. Now close to 80%-90% of the patients stay where their initial care was rendered, which is a big win for everybody. It brings value creation to the referring hospital. They keep the patient, they keep the DRG, it brings value to the flagship, which is at now under tremendous pressure because of too many admissions, too many people in the emergency room. So keeping patients out who don’t need our specialized services meets our academic mission, helps address capacity management issues and is being looked at as a model increasingly to think about critical care and other high intensity resources that we could potentially manage remotely and keep that value, that lower cost of care in the community.

So that’s kind of a big picture summary. I will say that our fastest growing product now is TeleNeurology, which has basically been the further expansion of, “Hey, this service is great. Hey, it helps me with stroke, can I get you to help me with everything else?” And so that has actually become our fastest growing service and the place where we’re seeing the most opportunity for innovation and creativity because it’s a wide spectrum of diseases and our whole approach to protocol driven care and evidence-based management has had to evolve in response to that.

Lloyd: That’s awesome. I’m actually going to lean into, first, the metrics that we talked about and developed as part of the case study back in 2021 on the telestroke program itself. But then I have some questions after about the evolution of the program, and I think some other ways that I would be interested in hearing how you might be measuring the success of that program from an expansion perspective.

So as you likely recall, our Return on Health framework looks at quite a few value streams, clinical outcomes, access to care, patient experience, clinician experience, financial impact, and then health equity. When we developed the case study with you a few years back, Mass General Hospital was measuring a few key things from an outcomes perspective, door to needle time, time to consult for access, and then patient and clinician satisfaction scores. What I love about that, is you were looking especially from a clinician perspective, both at the satisfaction scores not only in the Mass General system but also in the community hospitals you were serving and very similar to patient retention and reduced costs to families and patients from a financial perspective.

So any updates on those key areas, those metrics, anything else you have started to measure that’s been particularly impactful to speak to as part of the telestroke program?

Dr. Schwamm: I think that framework has largely been continued the way we described it. I think one thing that is really unexpected and really exciting in our teleneurology program, we started looking at time to consultants from requests to consultant, rendering an opinion for inpatient teleneurology patients and compared it to in-person response by the neurology group that was employed by the hospital. And actually, to our surprise, but not so much maybe when you really think through it, we had a shorter time from request to consult, and to definitive diagnosis and management plan compared to in-person. And that led to a significant reduction in length of stay. And that length of stay was not shortened through increased transfers out of that hospital to our hospital. It was actually the same proportion of transfers, discharges to home, discharges to other facilities.

And I think what it speaks to is just what you would imagine if you were running a restaurant or some other business. Little delays by themselves seem insignificant, but they stack up like airplanes circling for the runway. And so you miss an opportunity, well then it’s another 24 hours before the MRI can be done, and then it’s another 24 hours before someone looks at it, and then it’s another 24 hours before the EEG gets done, and then the consultant comes back after all the tests have been done. As opposed to getting the expert opinion upfront, maybe you don’t even get the EEG or maybe you get the MRI that day because you ordered it by 10 a.m. not by 4 p.m. So these little things, it’s just like in the in-hospital work, if you can get discharges out by 10: a.m. instead of 11, or 12, or 2, you get like 10% more throughout just magically because of all of the sequential nature and the waterfall aspects of that.

So that I think is a really important thing to track. I think tracking experience and understanding usability and getting real time feedback, but also periodic accumulated feedback from the program managers, is something that’s always been baked into our program, and building out dashboards that the remote site can pull up any time and access in a self-service capacity, I think is still underutilized by some of our sites, but is heavily utilized by others. And in fact, is often pointed to when they undergo audits by the joint commission or their Department of Health on their stroke program, they’re very proud to show the data that they have available about the care of the patients.

I think in terms of outcomes, that’s where it gets a little bit hard because there’s so many other factors that contribute to say a 90-day outcome after a stroke, because we are a consulting service and we don’t admit those patients to our hospital and we don’t create a medical record for them if they never come into our system.

We don’t really have the ability to reach out to them at 90 days and say, “Hey, this is Mass General calling to see how you’re doing.” They’re like, “I never got treated by Mass General.” The best part about this is that the patients think they’re being treated at their local hospital by a special consultant who’s kind of had a guest appearance on the TV screen. Because of that, I think one thing we really do need is we need standardized outcomes that everybody collects on stroke patients no matter how their care is rendered and then access those metrics. But right now, those are not required by payers or by policy.

The only other thing I would mention is around the health equity piece: There’s two things that I think are really important to highlight. One is, we looked at the population of patients we treat in our front door and we compared that to the population of patients we treat over telestroke.

Telestroke dramatically increases both the racial, geographic and urban rural diversity of the patients we serve. So this actually allows us to reach out and serve a much more equitable population of patients. And when we have evaluated our own metrics to look at time to treatment and outcomes, there’s no impact of social drivers of health. So we treat the patients who are Hispanic and Spanish-speaking primarily the same as we treat the white sort of Anglo-Saxon English-speaking patients. And that’s great because that demonstrates once again that standardized frameworks, standardized protocols and a high reliability systems tend to eradicate a lot of the implicit bias that may be present when we evaluate patients on a more informal basis. So we’re very proud of that fact as well.

Lloyd: That’s awesome. And I think that was something a couple years ago that we didn’t have as a metric quite yet, and that’s definitely an evolving space. So, really excited to hear that update. A couple of other, I guess questions I would have in terms of, I would say more system-type impacts. So you spoke a little bit about the growing space in teleneurology. Are there additional kind of programs, and I think this really speaks to that clinician experience at the community hospitals and the partner hospitals and kind of that hub-and-spoke model of expanding the services that they want Mass General to support them on. So would love to hear a little bit more about where you see growth happening beyond the telestroke and teleneurology there?

Dr. Schwamm: Yes, so that’s a great question and I think it speaks to understanding the shifting frameworks around fee-for-service versus value-based arrangements. Understanding where is a service really subcapitated? As opposed to where is it really being purchased as a fee for service experience? We have had our greatest success in packaging these relationships as subcapitation. We are providing you with a wraparound, it’s sort of like consultants as a service. And so you get it by phone, you get it by video, whatever modality is the most appropriate. Maybe it all starts by phone and then goes to video when necessary. Depends on the scenario.

We’ve had a really interesting lessons learned and experiences with a neonatal ICU telemedicine program. Interestingly enough, one of the things I love about that program is not only are they providing remote neonatal ICU care and rounding, but in fact, at the Boston location when there are children can stay in the neonatal ICU or the pediatric ICU for weeks or months before they’re ready to go home. And many times there are parents who just can’t stop their lives to be there every day, but they want to join rounds. And so they did a lift classroom model where now the parents are joining over video to be present on rounds when the team is rounding in person.

So that’s when I talk about innovation and value creation, like those are patient experience or family experience contributors that don’t get marked up on a balance sheet, but drive reputation, trust, word of mouth, that those can be really important. That can make you decide to have your baby at that hospital because, “God forbid my baby had a problem, that’s the hospital I want to be at when I give birth” kind of thing.

So that’s one thing. I think the second thing is what’s the future of the tertiary or quaternary care hospital? It has to be focus on quaternary and tertiary care. It can’t be making its bread and butter off of primary and secondary care. I don’t think our health economy is going to tolerate that. So telemedicine and other digital tools is really fundamentally a way to think about attribution of care, right side of care and really managing a population of patients. Even in an acute episode, you’re still managing a population of patients, because where we used to think of who are the critically ill patients? They’re the ones in my ICU, then we would say, "Well, they’re the ones in my ICU plus the ones on the floor who can’t get into the ICU yet because I have no beds, so I’m managing them on the floor." It’s not great, but I’m going to get them in soon. And then we said, Well, OK. And then there’s also patients in the ER who haven’t been admitted yet, but they’re critically ill and they’re just waiting for a bed also, and I have to figure out how to balance the load between those and the inpatients.

And now we’re realizing, well, it’s also the critically ill patients in my community hospitals and actually it’s the critically ill patients in the entire community, all of whom are applying pressure on these quaternary systems for the sickest patients. This finally gives us the dashboard and the toolkit to manage a population, for example, of critically ill patients and flexibly moving them in or to the front or the back of a queue that needs to be transferred. Maybe the assumption is I try to manage you locally as long as I can, knowing if you deteriorate, you get to come right away. So I’m managing six or seven or eight outfielders, we would call them, through telemedicine-supported programs. And at the same time, keeping that patient in that community hospital subtly is increasing the capacity of that hospital to care for the next patient and the next patient. So you’re really building program growth.

Now, that is separate from another space you alluded to, which is building new capacity explicitly at community hospitals. So epilepsy monitoring is a nice example. We do long-term monitoring of patients three, four days at a time, continuous EEG monitoring if we think they might be candidates for epilepsy surgery. That’s typically a fairly high margin activity confined to the tertiary care hospital. But I don’t really need to monitor you for four days at Mass General to do your surgery at Mass General. I could monitor you at Lake Shore Community Hospital.

And so building out that capability with standardized protocols, similar equipment, same expectations so that I don’t have to repeat anything, it’s all done the way I would’ve done it here. So it becomes site independent and transparent. And guess what? If you’re having trouble reading that EEG, now I can just pull it into my work queue and review it as well, because we have shared tools and we can all jump on a Teams or Zoom conference to review the results in a standardized monthly case review conference.

So this is where, again, that whole concept of building out a health system that is responsive to our patients’ needs and experiences, keeping a patient local—way better than dragging them in downtown and dragging their whole family in downtown every day—and really increases value. Now it does not save money and cut costs on your quarterly P&L, so you can’t hold it up to that lens as the only rationale for why you’re doing this. You have to build out this broader return on value, return on health kind of framework, which is why we were so excited to participate in this exercise.

Lloyd: I love that you pointed that out because as you mentioned, that’s the whole reason that we wanted to create this, because you hear so many people talking about the dollars and cents of it. And I’m like, there’s so many other things that really go into creating value, and creating impact that ultimately can translate into dollars and cents. It’s just not direct, the way you think about revenue. So, really appreciate your thoughts on that. And it sounds like measuring the things that you have measured as part of your program have only led to expansion.

So that kind of leads me into my next question, knowing that tracking the impact of these virtual care programs are really crucial today as we think about just the future of digitally enabled care, the future of telehealth with the end of the PHE, it sounds like the measuring piece has helped you grow the program, expand the program. Are there other aspects of payment for these types of services, policy changes, that this program has helped to create at Mass General in the state of Massachusetts beyond that you could speak to?

Dr. Schwamm: So I will say a couple things in that regard, and everything flipped with the pandemic. So pre-pandemic, there was almost no direct to the patient in their home telemedicine, certainly almost none in Massachusetts. We were piloting some small stuff, but it was dwarfed by our dominant hospital-to-hospital inter-facility programs, which by the way are really not impacted at all by the PHE. And that because our docs were fully credentialed that those hospitals fully licensed in those states, it’s a high burden to get over. But once you have enough scale in your program, we were already doing all that. So nothing about the PHE created opportunity for us in those kind of programs. It massively expanded our visit volume. We did 10,000 virtual visits to the home in the year prior to COVID starting on March 15. And from March 15 to the end of September, we did one almost 1.8 million visits.

So just staggering flip there, and then obviously and went up to 60% to 70% of all visits being done virtually because the total denominator dropped dramatically. So now we’re back to most health systems are somewhere between 10% to 20% of all visit volume is virtual, some specialties way higher—like behavioral health in the 80s and higher. Some programs very close to zero based on the nature of the specialty. So the telestroke program was certainly instrumental in demonstrating to the congressional budget office and in modeling exercises we did with the American Heart Association that you should pay for telestroke no matter where the beneficiary is. So whether they’re in a rural hospital or in a close hospital, that shouldn’t matter. Now we don’t actually do direct billing. In our model, we assign the benefits to the hospital we’re consulting for some of them billed for it, some of them don’t.

For most hospitals it’s still such a small number of consults a year that the revenue capture hasn’t been worth the administrative burden. I think as these systems continue to grow, that will change and a big chunk of this will be used as an offset to program cost. But I think that the real challenge that we face now, with all of these telemedicine expansion, is number one, not being held to unreasonable standards of value that we don’t hold in-person care to. So for example, is it really adding value for me to see the post-stroke patient at 90 days virtually? Well, I would say no one has ever questioned the value of me seeing them in person. So why are you questioning the value of me seeing them over video? It’s still the same amount of time on my part. It’s still the same malpractice expense.

The only thing that might be less is some component of the in-office practice expense and they still have to do all the work. We still have to coordinate the visit, we still have to do the aftercare, we still have to coordinate the testing. That’s harder to do when you’re on video rather than in person because it’s another transaction. So I don’t really see that the cost of care, in that regard, is lower. Where we have to get to wring the real value out is in being able to liberate the real estate. If I know I’m going to get paid for telehealth permanently, even if the rate is slightly less than in-person, then I can start to repurpose my real estate. But I’ll tell you right now, there was, very briefly, legislation waivers that going to expire and the Ryan Haight Act, which controls, which regulates the prescription of controlled substances, was about to kick back in such that you had to have an in-person visit in order to prescribe with a 30-day grace period if you were already prescribing. There’s no space for all those visits, and all those visits would’ve to happen within a month because that’s the duration of the prescription.

So you just think about, we’ve already repurposed behavioral health and substance use disorder real estate because those clinics are all virtual now, so they don’t have a place to come in. There’s a lot of pediatric visits that have been repurposed to virtual. So the only way to wring the real value out of this, is to think about, really, the footprint, the physical and digital footprint and readjusting those.

So I think that some of these have been really important drivers. There’s a lot of focus right now on churn and whether telehealth really adds value, does it just increase cost? If I see you over telehealth and then I see you in person three days later, is that a marker of bad quality or great quality? If I saw you on video first, and triaged you to an in-person visit because there was a finding that was really important to address, that’s great care. If I’m just reduplicating everything and seeing everyone video first and then all of them in the office the next day or whatever, that’s wasteful. So building those models that allow us to extract that kind of information from claims—not there yet.

Lloyd: I am happy to hear you’re seeing progress, but I think hearing across the industry and with other folks that we talked to, kind of similar sentiments in terms of still just work to do and the right data to be able to track, and things like that. But I’ve often struggled with the focus on, well is it creating more visits and more money? I would argue if there are more visits, that might actually mean that there’s more folks taking care of themselves that will ultimately eliminate higher dollar costs in the future of those emergency room visits, those urgent care visits, those hospital stays, because we’re tackling things and folks are more willing to jump on those telehealth visits to address things earlier, versus waiting until they get to a point where they’re a little more acute.

Dr. Schwamm: Let me just, I wanted to give three quick responses. So that is really important. So don’t measure it if you’re not going to do something with the data. And so if you’re just going to put a remote blood pressure cuff on someone but not actually change their medicine, there’s no value there. There’s a little value, maybe they become aware, they really are hypertensive, but if you look at the RPM data, all the actions in the first three months, that’s when all the med changes are happening. That’s when all the visits are happening and that’s great. That’s a sign of better care because they need intensive intervention to get to management and get to control. Once they get to control, they need to shift into more of a maintenance mode. So maybe payment needs to be tailored differently, rather than pay per visit it’s a premium around pay for control in the first three months and then more of a maintenance model going forward.

So we need creative payment models and under alternative payment contracts, you can build those all internally. You can create an internal performance framework to insulate people. I also get really worried when it gets announced that a Medicare rate or the commercial payer rate is going to pay 80 cents on the dollar for the professional fee or discount the practice, whatever, and everyone freaks out and it’s like, “I can’t do this anymore. They’re not going to be paying me enough.” And you realize we’re talking about like 20% of all visits and of that like a 10% reduction. The actual dollars are tiny, but we don’t build these robust frameworks to shield providers from that emotional and/or financial experience.

I always tell my colleagues, you would never tell your secretary, “Sorry, I’m not booking any more Medicare patients this week. We’ve seen too many of them. They don’t pay well enough.” We don’t do that, right? We’re payer blind, so we should be modality blind. You should pick the modality that works to deliver the care. We also have no way of tracking in our current systems that, Stacy, I offered you a virtual visit but you declined and would prefer an in-person.

So I don’t actually even know the true yield of what I could convert to virtual because I don’t have any way of tracking, were they virtual appropriate? And the last example I’ll give you is in actual medical care, we used to put these very specialized and somewhat dangerous catheters into patients in the ICU. They were called pulmonary artery or Swan-Ganz catheters and they measured the pressures inside the chambers of the heart, and it was a large study. They were indispensable when I was in my training years—indispensable. You couldn’t be in an ICU and not have one of these if you had any degree of heart failure or low blood pressure or cardiogenic shock or any of that. There’s a big study done that basically showed they don’t actually change outcome. And it’s because most of the time people are not managing based on the numbers. They have a hypothesis, they put in the catheter, if it matches their hypothesis, they treat the way the catheter says. If it doesn’t, they treat differently based on their hypothesis. And so we don’t put them in very much anymore.

So I think we’re going to have to get to a place where we understand when is it adding value? And when it adds value, we have to pay attention to the outcome. And increasingly we want to use autonomous software to monitor adherence to a pathway and alert us when someone falls off the pathway and not leave it to fallible humans to remember to check and see if Stacy’s still on the pathway. We want to knock on my door when Stacy falls off the pathway. And I think that’s the only way we’re going to get to scale with truly leveraging digital technology.

Lloyd: Well that’s a great segue into to my next question. The AMA recently release the Future of Health report and it’s really trying to look at the digital health disconnect, which is really the gap between the potential for digitally enabled care in today’s reality of both in-person and virtual care, kind of being two parallels, versus creating that seamless experience that delivers right care, at the right time, with the right modalities.

So speaking to that kind of piece of what we just talked a little bit about, so I’d be interested in hearing from you, looking at current and future programs involving digitally enabled care, both at Mass General and, potentially even, and we’ll get to this, in terms of what you’re excited about for your new role. Is that happening? Are there any places where you feel like that seamless experience is working really well? Also, then kind of a follow-up to that is, what are the challenges and probably biggest barriers that still exist to getting there?

Dr. Schwamm: This is a great question and very just stimulates all sorts of rich thoughts. When they first started making movies, you know what they did, they mounted the movie camera on a fixed platform in the mezzanine section of the audience. And then they did the play the way they’d done it before but filmed it. So it was like a analog play captured on film. I think a lot of what we do today digital is we take an analog process, and analog workflow, and we try to stick some digital widgets in between. It’s like the first digital watches or just numbers on a watch, just like an analog watch, no other functions. Now of course the thing you do with your Apple Watch—the least is probably look at the time, right? It’s a digitally native device on your wrist leveraging all sorts of functionality that also helps you as a time piece, we have not yet entered the era of digitally native design to improve health care.

I think we have pockets of innovation, we have pockets of programs. I think the big drivers of innovation in this space are coming from the organizations that have fully embraced value-based care because they have the flexibility to try these out without the same kind of penalty that fee for service systems do. Although ironically, the fee for service systems often have the biggest hoards of cash to invest in new kind of innovative concepts. So it’s an interesting sort of dichotomy there. I think that the industry is just starting to embrace deeply the concepts that have been present in the marketing world for more than a decade of thinking about personas, thinking about journey mapping, really thinking about experience-led portfolios. We have a long way to go to redesign health care for value and to use digital enablement to help us.

Now, there are big places where you’re seeing traction, revenue cycle, thinking about the patient financial experience, putting tools right in patient’s hands to instantly pay their bill, pay their copay, request a financial payment plan, texting notifications, embracing the sort of modern digital approach to financial transactions, which leads if nothing else to accelerate, called cash acceleration, getting the revenue in sooner, which has value for a health system, especially when most payers are giving you payments 90 days in arrears or more.

So I think that we’re at the cusp, but we’re not quite there yet. I think we’re going to need some help from somebody big, big payer networks or CMMI, Medicare innovation. We need a new generation of fearless leaders who are going to take the plunge and have figured out and created very trustworthy, very sophisticated economic models that tell them just how much value creation they’re getting, and these downstream revenue impacts that everybody wants to take credit for. We need a better economic model that says, “You get one quarter of the penny, you get two quarters of the penny.” I don’t know where that last quarter of the penny gets attributed so we can have a carbon trading economy so I can actually get credit for and fund my program based on cost savings, and attribution and not just on what I call the dark green dollars that we bring in, not the light green dollars...

Lloyd: I love all of these impact metrics that don’t have a direct dollar and cents attached to them. Can’t say I’ve solved for what those translate into in dollar and cents. So there’s still a little bit of work to do, but with that said, it’s still important to keep doing these programs and they are showing value in different ways, and we need the time, and the space to be able to take that then and translate those impacts into dollar and cents. And to do that you need data over time. So I hope we continue to see folks really tracking some of this so that we can start to get some of that important data that we’ll continue to support the growth of these programs.

So would love to close this out with a couple of final thoughts from you, and then would love to hear what you are most excited about and for your new role at Yale, and what you’re taking with you from your past experiences to apply there?

Dr. Schwamm: We’ve touched on a few really important themes that matter a lot to me. One of them is, really rethinking design, really embracing sort of human-centered or patient-centered design and stop thinking about patients as patients, or as consumers, or as employees. They're people, and they have different personas when they’re on different journeys. So when your employee breaks their ankle, they don’t go into the employee portal to get health care. They go into the patient portal to get health care. So we have to think in a multidimensional way about the people we interact with.

We also have to start thinking about our entire supply chain environment. If we want to move into this different design model, we got to have our key suppliers and stakeholders along with us. So stakeholder mapping, stakeholder engagement, and shifting the normal progress of innovation, which typically in an academic medical center starts with, like, a physician with a neat idea, does a pilot, gets some traction, then goes to leadership, tries to convince them that this is a good thing.

I think instead, we have to start by saying, “What are the strategic objectives of the organization?” And force governance on the business owners to say, “How much bandwidth are you allocating to business as usual? How much you evaluate, are you allocating to innovation that’s targeted? And how much are you evaluating to just raw innovation?” You look at the NIH, tremendous amount of their budget is spent on just, “You send me good ideas, I fund them.”

I think in health care we have to be a little more thoughtful about that blend, that octane of how much we’re going to target strategic objectives and start really building for scale from the beginning. So not innovate something, cool, can it scale or not? Gee, it can’t, that’s too bad. Start by asking the question, can it scale upfront? And design for scale upfront.

So I would say all those things I just said, those are the things I’m really excited about trying to bring to Yale and to try to infuse this kind of design focus and experience focus to the way things are organized—so that we can start to build a kitchen where we kind of make new recipes in this new way, thinking about who’s going to be eating the meal and how many people we’re going to have to serve before we even start planting the ingredients.

Lloyd: Well I think I could talk to you all day. It was so great to talk with you today and catch up on progress of the telestroke program and learn about all of the other work that you are doing. And I’m really excited to see what you do at Yale in your new role as well. I’m sure we’ll be talking to you soon, and I think that’s going to wrap us up for today.

Dr. Schwamm: Great. Thanks so much. Have a wonderful day.

Speaker: Thank you for listening to this episode from the AMA STEPS Forward® podcast series. AMA's STEPS Forward® program is open access and free to all at STEPS Forward® can help put the joy back into medicine by offering real-world solutions to the challenges that your practice is confronting today. We look forward to you joining us next time on the AMA STEPS Forward® podcast series,

Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.