7 Takeaways From a Fireside Chat with Providence’s Chief of Virtual Care

“When a patient walks into the room and says to me, ‘Didn’t you see that in my chart?’ I almost want to scream.”

That was Dr. Eve Cunningham, Chief of Virtual Care and Digital Health at Providence, a seven-state, 52-hospital nonprofit health system based in Washington State. Dr. Cunningham was the fireside chat expert at MedCity News’ INVEST Digital Health conference in Dallas last week and was interviewed on stage by Senior Reporter Katie Adams.

In her candid comments Dr. Cunningham, an OB-GYN specialist, pulled back the veil on what makes primary care such a heavy burden and why it is so important that we lighten the load.

The Volume of Data is Itself Crushing

The electronic medical record (EMR) has fundamentally altered the work landscape for all doctors, but none more so than the primary care physician. Dr. Cunningham explained that when she went through medical training, a patient’s chart literally consisted of a folder with a couple of sheets of paper with information on the patient. Now, the ubiquity of EMRs and the sheer amount of the data being dumped into them means that “today, it’s estimated that anywhere from 50,000 to 200,000 data points are in a patient’s chart. How is a primary care clinician able to consume a patient’s chart?”

That’s why she feels like screaming when a patient points out that all the info is in her chart — and she is not even a primary care physician.

“I’m an OB-GYN, and I only have to do a chart biopsy on the little area around being a gynecologist,” Cunningham pointed out. “I don’t care about your knee surgery last year, but primary care, they’re responsible for all of it ….”

Meanwhile, when Cunningham was the chief medical officer, primary care physicians would tell her, “I don’t want to take any more new patients. I want to close my panel because every time I have a new patient, I have anxiety because I don’t know if I’m going to miss something.”

In other words, while the rest of us cheer the availability of so much healthcare data — because after all, without data there are no insights and without insight, there’s no improvement in outcomes — primary care physicians are drowning in it, especially because the information is not organized and as Cunningham put it, the EMR “is not smart.” That leads to the departure of primary care physicians.

“We’re seeing so many of our peers reducing their hours, leaving the workforce, going into concierge medicine. You want to know why they’re going to concierge medicine? They can spend an hour with their patients and their EMR isn’t connected to all the other EMRs that are dumping information in.”

To Be Successful In Healthcare, an Integrated Delivery Network is Critical

Adams asked why standalone primary care in the way Walmart and Walgreens envisioned has failed and Cunningham’s answer was straightforward.

“You have to have integrated care delivery,” she declared. “Now, you can have standalone components of primary care or extensions of primary care that are virtual only, but they have to integrate in with a integrated care delivery model or a brick and mortar that’s connected to an integrated care delivery model. Otherwise, it’s extremely challenging.”

Virtual Care Companies — Please Don’t Suck Away the Easy Stuff

Health systems often decide to partner with virtual care companies to take away some of the burden from in-person visits and lessen pressure on primary care, but the actual effect is the very opposite of what they are trying to achieve. It sounds counterintuitive. After all, why should the primary care physician bother with a low-acuity cough or UTI that can be handled virtually by a telemedicine provider? Turns out, the easy appointments act as somewhat of a breather for physicians.

“The chronic disease management burden is so immense, that a simple UTI in the office, that’s a win. It’s like, ‘Oh, thank God I don’t have to cognitively overwhelm myself for one 15 minute visit’, right?” Cunningham explained.

What has worked instead is a remote monitoring chronic management solution for chronic disease management, especially in congestive heart failure, hypertension and diabetes. Through this, the primary care physicians don’t have to manage a patient within a 20-minute time frame of an average office visit and the virtual care company becomes an extension of the primary care team because the nurse practitioners of that program work closely with the health system’s primary care physicians.

“So those are the types of programs that need to grow and scale. Partnering in a meaningful way, being mindful of the impact that you’re going to have on the workforce that’s doing brick and mortar work, and so that it makes sense to them and to their patients,” Cunningham concluded.

Telehealth is Not Dead

Walmart and Optum have both shuttered their virtual-only care businesses. Amwell and Teladoc have embarrassingly low stock prices, far off of their 2021 highs. Adams said that people like to say telehealth is dead, but the truth is that it is likely evolving from the heady days of the pandemic. She then invited Cunningham to weigh in.

Cunningham explained that telehealth is one of the main tools to help with the physician shortage and is certainly not dead. She said that Providence has a very large teleneurology program that covers 92 hospitals.

“And on any given day, I can have three neurologists on call covering 92 hospitals — that is bringing specialty expertise into community hospitals, rural areas where they would never be able to sustain a brick and mortar program,” she explained. “And we are able to reduce transfers by 70% — unnecessary transfers to bigger hospitals that don’t need to happen.”

She declared that the retailers failed because they didn’t hone in on areas that needed to be focused on or understand the problems that telehealth should be leveraged to solve.

“We have a teleICU program in Alaska, mainly in Alaska. We would not be able to have ICU coverage if we didn’t have these teleprograms,” Cunningham said, underscoring her view that telehealth is far from dead.

On the contrary, she is noticing that her colleagues are demanding more telehealth options.

“I get chief medical officers calling me with desperate calls — ‘When are you going to launch tele-cardiology’,” she recalled, noting that Providence launched a teleinfectious disease program a few months ago. “I believe every single hospital bed will have a endpoint for telemedicine in Providence within three to five years, and we’ve got 12,000 beds.”

Yes, You Heard it Here Again — Health Systems do Not Want Point Solutions

A thousand digital health pilots — the problem of a few years ago — has now led straight into point solution fatigue. Cunningham candidly admitted that Providence will largely not partner with health technologies that solve just one problem

“We can’t do a bunch of point solution integrations. We just don’t have the ability and the capacity to be able to do that. So we have to be really strategic and selective about the ones that we choose to partner with and integrate [with] and make sure that there’s more of a platform approach, multi-use case opportunity with those solutions.”

Bluetooth Pairing? Downloading an App? They are Dead on Arrival

It’s not just clinicians who have to figure out how to manage change as it relates to leveraging tech to deliver care. Patients also have to manage that change. So the less burdensome that requirement is for patients, the easier it is, especially given that many chronic disease patients are older and may not always be comfortable with technology. So what’s the solution?

“I will say for technology where you’re going to have to have the patient use something, it’s got to be really simple and straightforward. Bluetooth pairing, downloading apps, having to have a password? Like forget it, dead on arrival. Our remote patient monitoring is Medicare-aged folks. They take the device home or it gets shipped to them, they press a button, it connects and we’re done. That’s it,” Cunningham said.

To her, the simplicity of these tools guarantees the “tech equity” component of care.

Human in the Driver’s Seat — That’s How Providence Looks at AI

Cunningham explained that while the healthcare industry is bullish about AI, the actual reality on the ground is far more measured. Providers may be sold on FDA-approved algorithms in radiology, imaging and pathology, but there are legitimate concerns about other aspects of the technology. Right now, health systems are embracing AI in the back end administrative tasks, as opposed to in clinical decision making or directly at the point of care.

“We do have things that we are comfortable with from an administrative task perspective. We use the Microsoft Copilot and different products that aren’t necessarily impacting clinical decision making,” she explained. “But right now I would almost describe it as AI tooling, ‘How do you augment and accelerate the work that humans are doing?’ But the humans are still in the driver’s seat of that.”

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