Data and Telehealth: Breaking Down the Barriers (ft. David McSwain)

Thanks for tuning to Digital Voices podcast, where we chat digital transformation challenges and opportunities across healthcare and life sciences. And now, your host, Ed Marx.

Hey, it's Ed again. Welcome to another episode of Digital Voices. Today we'll be talking about digital transformation, physician executive leadership, point of view and one of the pioneers, I think, of the CMIO profession and certainly telehealth, been doing telehealth for a long time, will be Dr. David McSwain. Dr. McSwain, welcome to Digital Voices.

Thank you. I'm very excited to be here.

Yeah, I can't wait to jump right in. But before we do, because I know we're going to talk about telehealth, I wanted to ask Megan, and Megan being the mom and wife and the mom of a young child, telemedicine. Are you a fan of telemedicine? I am. I think it's great, especially for certain use cases. I've only had one experience using it so far, but it was definitely convenient. And I look forward to having that option for future visits. Yeah, I'll never go back in person unless I have to, unless they force me to go back. I'm all about telehealth, have been for a long time, but especially given what's happened in the last couple of years. So let's jump right in. So David, you and I first met mostly online. I've been a big follower of yours for quite some time. You're a pioneer with the CMIOs. Definitely been doing telehealth a lot longer than anyone, or many, many people. Let's say like that. And certainly your move from South Carolina to North Carolina, and you know that was pretty interesting as well. I know you've got roots now in both places, but I appreciate the fact that you're willing to come on the show. And and as you know, the first song we ask—I say song—we ask because that's the question we're going to ask—is what's On your playlist?

Well, it's whatever my wife and daughter want to listen to, or my stepdaughter when she's in town. But seriously, I actually, I really like blues. I like music that's blues-influenced, you know, kind of the hybrid stuff. So blues rock, blues country, you know, bluesy soul. A fan of Nathaniel Ratliff and the Night Sweats, Chris Stapleton, Marc Broussard, Tadeshi Trucks, and older stuff like B.B. King. And I really like some of the classic rock bands that have a strong blues influence. So, you know, Rolling Stones, Creedence, and Lynyrd Skynyrd. But it's interesting, you know, music is actually something that my wife and I first bonded over. My wife is Brooke McFlane. She's a brilliant health IT policy mind and somebody you should probably have on the show. But we, you know, we bonded over music and telehealth. We started out in telehealth together. And, we would go and visit these rural community hospitals to set up telemedicine programs there. And, pretty early on in these road trips, we realized that we both shared similar interests in music and we both sang. And, I sang in college and she actually sang in a band. And so, of course, within a short period of time on our first road trip, we're just belting out songs together in the car. Interestingly, we now have a bit of a reputation, especially at academic conferences, where we will host Dave and Brooke's karaoke night at the conference. And pre-pandemic especially, they were really well attended and a lot of fun. So yeah, music's always been a big part of my life.

That's really cool. And I'm going to remember that when we're, when we're together in person someday and we'll go do some karaoke. That's always a lot of fun. We had a some singing musician, uh, physician leaders when I was at Texas Health. Dan Varga, who you might know. And so at night after the board meetings were done, we would all meet up. There'd be like 4 or 5, 6 of us meet up in the lounge and, and just start creating music. And so that was a lot of fun and a lot of good bonding moments. So music can do that. And that's one of the reasons we ask that question, because it's always interesting response that you get from people and sometimes some new bands to look up. What about your area of passion in life, or is there a message or a mantra that you have that sort of guides you along the way?

Yeah, it's always do the right thing for the right reasons. And that sounds simple, but really it's not about feeling like you know what the right thing to do is every time you enter into a discussion. It's about understanding that really you don't and you may not, and going into the discussion really looking to discover what that right thing to do is and Always keeping that North Star of what's the thing to do that's going to help the most people? What are the ultimate goals that you're really looking to achieve? And when you are meeting with a lot of people, maybe with some different viewpoints, you can look at it from that perspective and recognize that oftentimes, there are people with differing viewpoints who everybody in the room really wants to do the right things for the right reasons. They just have different ways of getting to it. But if they all are trying to do that right thing, then there's always a path forward. And that's the important thing to realize. It helps you maintain a sense of optimism if you realize that everyone that you're working with, everyone that's in this discussion, even if they're arguing, even if they have different viewpoints, even if they seem to be at an impasse, if you recognize that they're all trying to do the right thing for the right reasons, then you can find a way through it. And that's always been the way that I have approached it. And, you know, it helps you also to identify your teammates, to identify the people who are trying to do the right things and to work with them and support them and develop your team, even if they're not in your department or in your institution or even in your state. And I've had a lot of experience with, and you can really accomplish some amazing things that way.

Yeah, that's good leadership philosophy right there. I love it. Yeah, 'cause oftentimes, You'd find yourself like almost like the person on your team is your enemy, but they're not.

No.

And within your healthcare system, you'd be fighting each other. It's like sometimes someone have to just point out what you're pointing out. Look, we're all trying to do the right thing and we're all on the same team and we're all trying to help heal people and bring wellness and things like that. That's really good. I think sometimes we forget it. So thank you for sharing that. We learned a little bit about you already in terms of singing and how you met your wife and those sort of things. But tell us a little bit more about your story, personal or professional. But how did you come to who you are today and your role today?

The reality is, I'm not really a very technology-focused guy. I've always been a problem-solving-focused guy. But, increasingly, the issues around technology— technology gives you the opportunity to solve a lot of problems. It's part of the solution in a lot of ways. In some cases, it's part of the problem. And, you know, so if you are taking a problem-solving approach, then you kind of naturally, organically progress towards technology-focused solutions. And the other thing about my own personality is that I've always been drawn to complexity. You know, the more complex, big and complex the problem is, the more likely I'm just raring to go to jump into it and try to work with people to find a solution. It really kind of makes me excited to think that we could solve solve this big problem. And that's really been a guiding influence in my career. I grew up in the foothills of North Carolina, about 45 minutes west of Charlotte. My family actually settled that area in like 1700. So, I have certainly very deep roots in that region. And I went back and forth between Duke and UNC for undergrad, for med school, School of Public Health. I did an internal medicine and pediatrics residency at UNC and then did pediatric critical care fellowship at Duke. And really coming out of fellowship, when I began practicing as a pediatric intensivist, one of the problems, one of the really striking problems that became readily apparent to me was that when children were presenting to rural community hospitals critically ill or injured, that we had to get on a phone with somebody from the outside hospital in a chaotic situation. possibly poorly resourced facility and gather the best information that we could in the midst of all this and provide recommendations and try to get them stabilized for transfer. And that could just be extremely difficult. And it resulted in some outcomes that I was certain we can make better if we could do a better assessment and have better communication and gather more information. And so I developed one of the first pediatric critical care telemedicine programs in the country. Not the first. There was some real pioneers in the field that helped me along the way there. And my career in telehealth really grew from there. And as I grew in that space and became more engaged in multiple aspects of telehealth, I began to identify bigger problems, bigger, more complex problems, which is what led to me with a wonderful group of pediatricians from around the country co-founding the National Telehealth— National Pediatric Telehealth Research Network called SPROUT because we're wanting to address one of the biggest problems with telehealth and virtual care adoption and policy and regulation, which was the lack of really rigorous evidence. And so we took a very team-oriented approach to that, and we were able to get a lot of support. We got NIH funding. And that approach to building alignment for complex problems is one of the reasons that I was recruited into my first CMIO role back in 2018, because I focus on communication, understanding people's perspectives, and building a network, building collaborative approaches. And I've grown in that role ever since, and I just have wonderful teammates that I've learned from and really continued to identify new problems to try to tackle.

That's spectacular. And I know, like I said, DJ Megan has a young child, and I've had 5 children. And I could think, as you were sharing, multiple times where that sort of network that you talked about with something like Sprout would certainly have been super helpful. And I'm glad to see clinicians like yourself take that on. So you recently made a pretty big move, though. You went So even though all your foundation and education was in North Carolina, you crossed the state border, you went to South Carolina where you served for quite some time, and most recently came back to North Carolina. Tell us a little bit about that change.

Yeah, well, you know, it was great. It's really moving back home in a lot of ways, but also UNC is a wonderful institution with a lot of really amazing people, and they've done some amazing foundational work in the health IT space. And there's a lot of people that are still here that I knew and really liked and respected from when I was in medical school or when I was in residency. And that says a lot about the culture of an institution. Those people are not only still here, they're in leadership positions. And when you are elevating your best people, when you're retaining your best people, putting them in leadership positions, it says so much about the culture of the organization. UNC is a place where talented people feel valued and empowered. That's the kind of culture that I was really excited to be a part of. I get to step into the shoes of the departing CMIO, Don Spencer, who just did a wonderful job. He was in the role for over 20 years. I had the opportunity to step into this role back at what I consider to be my home institution and pick up on some amazing work.

Yeah. How fun is that? Like you said, it's a place where you trained, you grew up knowing all about. UNC, it's been such a great institution for a variety of reasons, and then you get to come back as a senior executive and help continue the great care that's taking place there. So that's pretty cool. Now, you have been in telemedicine for quite some time. So even though it may have been sort of accidental in a sense, you've been engaged with telemedicine and a long time. It's almost like dog years. Like, if you're engaged with telemedicine these days, you're 7. So you've been around it since— for maybe 7 to 10 years. What are 2 or 3 major changes that you've seen? You know, obviously one's the pandemic, right, that accelerated things. But in addition to the pandemic, are there any other major changes that you've seen in the last few years?

It's been 12 years. So in telehealth years, that makes me ancient. But, you know, obviously the pandemic was a huge factor. But the interesting thing is, you know, I was on a webinar back in May of 2020. And shortly after telehealth had exploded in response to the pandemic. And I said then, telehealth leaders need to recognize that the pandemic is going to change their approach to the rest of healthcare as much as it's going to change the rest of healthcare's approach to telehealth. And people kind of looked at me like I was crazy because this was this triumphant moment for telehealth, right? This was the time when everybody in telehealth was saying, I told you so. And here I am on this webinar. Saying, well, hold on, we're going to have to evolve. Telehealth has to evolve. And what we're seeing is that evolution because pre-pandemic, telehealth in many ways was siloed. It wasn't well integrated with usual healthcare practice. It wasn't well integrated into electronic health records. The workflows weren't well integrated in many cases. And a lot of the telehealth industry was focused on providing services that were somewhat separate from the patient-centered medical home, from the primary care provider. They were focusing on providing on-demand services to the wealthy walking well that could pay out of pocket. And what we saw with the pandemic is suddenly institutions and providers are forced to integrate telehealth and virtual care into their day-to-day practice. And that's the biggest change. It's that shift towards an integrated approach, integrating telehealth into the EHR, integrating telehealth into standard practice. And I think that's the thing that we need to hold on to very tightly because the greatest potential for virtual care is in a hybrid model where the same providers who are providing in-person care are also able to provide care remotely. And where your patient is located is not the most important factor. determining whether and how they receive care. So that's really a huge shift. The other big thing that we saw, and this was, I think, surprising to a lot of people, is the negative impact on health equity that resulted from the rapid expansion of telehealth. And I think that was a really eye-opening thing. And we, with Sprout, we did some work that helped identify some of those issues, particularly around the use of audio-only telehealth as opposed to video telehealth for disadvantaged populations. And telehealth and virtual care was always billed as one of the solutions to health equity and one of the solutions to access to care. But the data showed us shortly after the pandemic kicked off that that wasn't really what we were seeing in every case. And so we needed to refocus on how do we approach this in an equitable way. And then the last thing which ties in with that is the importance of data and research. And this was a drum obviously we were beating with Sprout for a long time prior to the pandemic, but it has become apparent, especially as we're emerging from the pandemic, that we desperately need data to inform our policymaking decisions, to inform our treatment decisions. integrated practice development to inform the regulatory changes. Thankfully, a lot of the work that we've been able to do with Sprout around creating measurement frameworks, creating policy evaluation frameworks, creating economic evaluation frameworks has been very helpful in helping to move that forward.

That's a really good analysis of that particular issue or things that have changed because I recall even in 2018 when we were writing a book on innovation, where we looked at inner city Cleveland, only 25% of the population had broadband capabilities. So we think telehealth, oh, it's going to be health equity, right? Everyone can use it. No, hardly anyone could that really needed it, right? So the fact that you acknowledge the voice only and that there's other things. And yeah, the data and research is something that's been lacking historically. It seemed to make logical sense, but you can't make arguments And investment decisions based on sort of those feelings, but you need to back them up with the data. So again, you know, kudos to you and your colleagues at Sprout and others who are, who are finally tackling sort of this data and research that's needed because it is, as we both know, it is a great platform. It can do many, many great things. And, but we need to just strengthen it with a little bit of science and, and rigor to continue to, to get everything we can out of it. In your role, obviously, senior executive and a physician and digital and all those sorts of things, and things change so much, right? Even in clinical practice, it's very difficult to keep up. How do you keep up to date generally with all the changes that you see in technology?

Well, I think you really maintain a focus on the core problems because, if you get too focused on what you believe is the solution, you can get tunnel vision towards that solution. You have to realize that the problem is never really static. And focusing on how is the problem evolving and learning how are the barriers evolving is a really effective way to stay current. Because if there weren't barriers, then it'd be done already. So the fact that you're still having to work on something means there's barriers that haven't been fully addressed. And that is where I think you can really have the most impact as an executive leader, helping to identify and articulate what those core barriers are that are really preventing movement forward on some key initiatives. So I really focus on that. I also stay clinically engaged. I still work in the PICU. And I think that's incredibly important for the CMIO role, not only so that you understand the clinical workflows and how the technology can impact that, but also because some of your best ideas come from your fellow clinical colleagues, right? They're very thoughtful, engaged people. They're always thinking about how best to help their patients, and they come to you with ideas. And it's just, it's a wonderful opportunity to hear those ideas and to move them forward.

Those are really important, what you just said, because oftentimes we can be sort of distracted by the bright, shiny object type thing and we lose focus on that core problem that we really need to tackle. And the fact that you continue to be active in your practice, yeah, I agree, makes a tremendous amount of sense. What are maybe like 1 or 2 key areas that you're working on now, these core problem sort of things for UNC?

Yeah, well, one of my major focuses is on getting technology out from between the patient and the clinician. And I think that's been one of the major issues that we've seen over the past couple of decades is that technology that, that held a lot of promise has actually come between the clinician and the patient and has contributed a great deal to a lot of the burnout that we're seeing, to patient dissatisfaction, to staff and provider dissatisfaction. Particularly things like voice recognition and natural language processing with AI and machine learning and mobile device applications, wearables, it allows you to get away from your computer, stand up from your desk, go actually interact with your teams, with the patients, and improve that engagement. And I think really focusing in on how do you maximize The engagement time with the patients? How do you make the clinical work in front of a computer more streamlined and more efficient, more effective? That's a really key aspect of improving everyone's work-life balance and also of improving the patient experience and the clinician experience.

I love that example that you're giving because you can impact both. In a positive way when you focus on that core problem at both the patient engagement and the clinician burnout. That's really cool. You're obviously a very scientifically minded, research-oriented individual. So I'm curious, how do you measure success of initiatives? So when you do, when you do launch an initiative or maybe you're working with technology people or digital, how do you measure success?

Well, it depends on why you're measuring it and how you define success. And that's a little bit of a nonspecific answer, I recognize, but it gets back to understanding the complexity of the problem. And one of the core focuses that we have with SPROUT, which stands for Supporting Pediatric Research on Outcomes and Utilization of Telehealth— wanted to mention that because possibly my greatest contribution to the organization was coming up with the name. But, you know, we recognize that the way you evaluate your program And this applies beyond telehealth. I think you have to understand who are the stakeholders that you're communicating with and what's important to them. If the sustainability of your program or of your effort is dependent on payment, then you better be paying attention to what the payers want to see from that program. If the sustainability of your program is dependent on patient engagement and/or clinician engagement and adoption, of a tool, then you better start thinking about what do clinicians want to see as an outcome or a metric associated with that program or that innovation. And so we start with defining the problem and defining it from the perspective of the stakeholders who are going to determine the success or the sustainability of the effort. Once you understand that, in many ways, the metrics almost write themselves because it allows you to translate a sometimes subjective issue or a subjective interest on the part of a stakeholder into an objective measurement or metric in a much more efficient way.

Yeah. And that approach then ensures that there's agreement from the get-go Because you're interacting, you're collaborating with your stakeholders. So there's no surprises at the end.

Absolutely. That's an important point because one of the greatest values to determining how you're going to measure a program is that it really effectively aids in the communication around the program and it helps determining how you're going to develop the program. Because if you recognize, as you're looking at different measurement options and you're evaluating those stakeholder perspectives, that the way that you've been planning to design this program is not going to actually result in a significant change to the measure that you've identified or that a stakeholder that you're working with has identified as one of their key areas of interest, then you better rethink how you're going to design that program, right? So it's incredibly vital to think about measurement and evaluation and research early on in the development of A program and start gathering the data. One of the greatest things, or the greatest impacts of the pandemic in terms of virtual care, is that because of the massive adoption, there is a huge windfall of data available to us. Now we have to take that data and turn it into knowledge and turn it into wisdom because we have an amazing case study in what telehealth looks like when it's integrated into the practice of healthcare. And we also have the pre, and now we're gonna have the post, and we can actually compare those things and get real rigorous evidence to show us how do we need to pay for this? How do we need to evolve this? And how do we design it in a way that's the greatest benefit to our patients, their families, and our clinicians and staff?

Yeah, you know, it seems pretty obvious and probably when people listen, oh, of course, you know, take baseline data, but you'd be surprised. Well, Dave, I don't think you'd be surprised, given your background and the way that you think. But when I've worked with other health systems, I'm very fortunate to have grown up in health systems that insisted on baseline data measurement, measurement, measurement. And that way, whenever we made a change, we could make adjustments if we weren't hitting the mark. And if we were, then we'd go to the next thing. But the number of health systems that don't measure, and I'm like, we're about to make this huge transformational effort. We should measure first to make sure and measure what matters and make sure that we understand what What we're measuring and what success looks like so we can know if we're doing the right thing, you know, and that have the right outcomes. But not everyone is quite there. So I, I think the, the lesson right there, just encouragement to those listening that if your organization's not big on measure, be that person that says, hey, before we do anything, let's baseline measure and then, you know, see how you're doing. Then you can make adjustments and really know if you're successful or not. I, I don't wanna put you on the spot, Dave, by making you become a visionary suddenly, but I am curious, And only going out maybe 1 to 3 years, 5 years may be too far, but where do you think we're headed as an industry when it comes to telehealth?

Well, I think that as our healthcare system is concerned, you know, even beyond telehealth, it's really heading towards mobility, use of mobile devices, use of wearables, getting people up and away from their computers. I think when you look at what has the greatest potential to really have an impact in the next 3 to 5 years, In terms of the evolution, it's moving towards that sort of mobile approach. And that means the use of mobile applications instead of sitting in front of a computer. It means the use of wearable devices. It means the use of ambient listening technology to allow people to be up and engaged during an encounter. And I think that that's one of the ways that we'll be able to address issues of burnout and issues of engagement. Now, there's the flip side of that, which is physicians are somewhat concerned and reasonably so, and really all clinicians that, you know, if you put all of these means of connecting to work in my pocket on my phone, I'm never gonna be able to disconnect from work. And you have to recognize that. And that's another thing you have to proactively address and you have to really gather information and communicate about that. You know, we're going to make your experience as mobile and as flexible as possible. That doesn't mean that you're always on 24/7. We'll put policies in place, we'll put guidance in place, we'll put technology in place to ensure that we put our providers, you know, top of mind in terms of innovating solutions. I also think this is— you say, where are we going in the next 3 to 5 years? And so, that unfortunately excludes my real aspirational goal, which is moving towards genuinely value-based care. And I think when you talk about core problems with healthcare, that's, I think, the fee-for-service payment mechanisms and the infrastructure that has been built up around that And the inertia of those approaches is a huge, huge barrier. And it's something that is going to take a really concerted effort over a long period of time to change. And technology plays a huge role in that because, really, when you think about how technology can function optimally in healthcare, it's in a value-based arrangement, right? Because in a fee-for-service arrangement, Incentives are misaligned, and you need to really move towards value because value gets at efficiencies, cost savings, improved long-term outcomes. And technology, when it's deployed well, the greatest benefit is to efficiency in many cases, and the ability to connect and maintain engagement in a way that can improve long-term outcomes. So really, the evolution of technology and the evolution towards a value-based care approach go hand in hand and need to be approached together.

Yeah, that's very well said. You know, I think you've pointed out a couple of barriers along the way. Certainly, sometimes regulation gets in our way, our payment models. It's not so much the technology. I think we have a lot of good technology today that, if applied appropriately, With all these other barriers taken away, we would really see the fulfillment of, you know, all the things that we would hope for as practitioners in terms of the best outcomes for patients, in terms of clinician satisfaction, you know, reducing burnout and creating healthy communities that we live in. So, wow, this has been really rich, Dave. We covered a lot of areas from the blues and now, yeah, definitely look up Brooke McSwain. And, uh, you know, everyone's gonna hit you up now for karaoke, both of you and Brooke, uh, for karaoke, uh, whenever we see you at HIMSS or, or one of your professional societies. But we covered a lot on, uh, everything from your philosophy about always doing the right thing for the right reason and the importance behind that, and, and covered a lot on telehealth and a lot of the cool things that you're all doing at UNC and things that you've been part of for years, for over 12 years with telehealth, including Sprout, providing more academic rigor and outcomes and just a lot of great things that, that you're doing. And I really appreciate the fact that you would spend a half hour with myself, my audience on Digital Voices, just sharing your perspective. And, uh, we wish— I think everyone listening is probably like, wow, we need a— we need someone like, uh, Dave McSwain in our organization. And, uh, I'm sure a lot of them have him, but a lot of them don't. And again, I just appreciate everything that you shared. Is there something that I may have missed or something we talked about that you wanna double down on as we end?

Yeah, I think a key point when you think about innovation and digital transformation is always focus on the populations that need it most. Always focus on developing things for the highest risk populations, for the patients who are disadvantaged, and not this idealized idea of a patient who's fully digital. Digitally literate and has a, you know, unlimited broadband data plan and, you know, has easy access to a computer in a private space. Think about, you should be designing your programs to have the biggest impact on the patients who maybe have a disability or whether it's physical or mental that don't speak English, that are not economically advantaged. And if you design your technology to help those people, Then you're going to have the biggest impact on the healthcare system as a whole, on populations, and it will also help those who don't suffer those same disadvantages. And I think that's such a key— that needs to be such a key focus as we move forward to really transform our system and to have the biggest impact on the most patients.

I love that. Dr. McSwain, excellent way to end our Digital Voices podcast. I can't, I can't restate that any better, so I'm going to leave it right where it is. Thank you for, again, being with us, and thank you to our producer, Megan. That's it for Digital Voices.

Thank you for listening to Digital Voices podcast with Ed Marx. If you enjoyed this episode, subscribe on your preferred streaming service and leave a rating and review. And most importantly, thanks again for listening.