Q&A with Dr. Eve Cunningham of Providence: “Let’s Talk about the Problems We’re Trying to Solve.

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“Technology is not the problem. There is so much amazing technology out there that can solve so many problems.”

And yet, clinicians remain increasingly frustrated. It’s precisely why Eve Cunningham, MD, left her role as CMO of a medical group in 2021. The technology that was being implemented wasn’t resonating at the point of care. The reason, she believes, is that clinicians weren’t getting involved, despite the fact that “most of the problems that need to be solved are clinical.”

Cunningham, an OB-GYN by training, started on a journey to change that. First by joining Providence’s Corporate Development team, which provides clinical strategy, innovation and product development support for its partnerships and incubations, then assuming her current post as Chief of Virtual Care and Digital Health. She also serves as Founder of MedPearl, a groundbreaking clinical decision support tool that aids in referrals and provides physicians with “specialized knowledge personalized to the patient’s EMR data.”

And she’s nowhere near finished.

Recently, Cunningham spoke with Kate Gamble Managing Editor at healthsystemCIO, about her team’s core objectives, particularly around virtual nursing, the importance of effective change management, and the genesis of MedPearl, what she termed as a ‘GitHub for doctors.’ She also talked about her advocacy efforts around telehealth and why more clinicians are – and should be – taking on digital leadership roles.

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Bold Statements

Once we were able to go in, prove it out, and then demonstrate the value proposition, people pretty much got in line and asked, ‘can I go next?’

You can’t underestimate the change management piece. I feel like a big part of what we do is change. Change management and supporting people through change — especially when people are already experiencing burnout and feeling overwhelmed.

We developed a platform in which we can create, govern, maintain, and collaborate as a clinician community to create digitally consumable, context-aware clinical content in a no-code environment. It’s basically like a GitHub for doctors.

All of these things were happening with technology, but none of it resonated with the point of care and with solving problems for the clinicians. The reason is because clinicians weren’t getting involved. And yet, most of the problems that need to be solved are clinical.

Twenty percent of our visits at Providence are done virtually. I testified on Capitol Hill early this year because if the reimbursement for telehealth expires at the end of this year, it will create complete chaos across our organization.

Gamble:  Hi Eve, thanks so much for joining us. Let’s start with some information about your scope and responsibilities as Chief of Virtual Care and Digital.

Cunningham:  Sure. So, I’m an OB GYN physician by training, and I lead virtual care and digital health. At Providence, we have a very large portfolio of products and services that are specifically focused around care transformation and how we get clinical care to transform and change the way we do traditional operations. Under the hood, we have three different buckets of things we do. We own the full operations enterprise services, including large-scale inpatient (mostly) telemedicine: tele-neurology, tele-psychiatry, tele-ICU, and tele-infectious disease.

Interestingly, we provide services to more than 90 hospitals. Providence itself has 52 hospitals, so we serve many non-Providence hospitals as well that are within our geographic footprint. We also have a product called MedPearl for which we own the full operations. It’s a digital assistant for clinicians.

Program collaborations

The second pillar is what we call program collaborations, where we own a component of the implementation, change management, and technology. There’s a business line within the organization that we help implement that product or service into, because traditional operations are just trying to stay afloat. For example, we come in and do remote patient monitoring in your primary care clinics and help them set that up. We do that with remote patient monitoring, remote therapeutic monitoring, tele-PT, and hospital at home. We figure out which pieces we own and which ones they own.

Virtual nursing

Virtual nursing is another example where we have the expertise in technology, change management, and workflow redesign. We come in and we help the team get to where they need to go. Sometimes we have to employ some of the nurses through our group, and so we have to figure out what component we share.

Shared services

The third pillar is more of the traditional shared services model where we’re the subject matter experts on all things billing, regulatory, compliance, technology, and workflow redesign for a program that maybe part of the system wants to own. One example is ambulatory outpatient virtual visits. That happens in the Providence Clinical Network, but we help them with getting their virtual visit platform set up and getting the workflow done and getting the training materials, and then they own the implementation in their respective hospitals or clinics.

“More collaboration” with IS

Gamble:  I would imagine there needs to be a lot of collaboration with the IS team at Providence.

Cunningham:  Yes, we have a lot of very close collaboration with them. But as you know, when virtual health was first coming up, it wasn’t part of the traditional IT operations. It developed as this separate business line within the organization that’s more focused on innovation and transformation. As telehealth has scaled and become table stakes, we’re seeing a lot more collaboration. And there are times where we say, ‘okay, this has gotten so big, maybe we roll it over to the IT division,’ because we’re constantly looking at things that are meant to innovate and transform.

The other thing is that we have a certain level of expertise in areas that IT might not traditionally have. For example, we’ll look at which cameras people might want on their carts. I have a huge amount of clinical operations under me and nearly all of the virtual hospital. We have 250 physicians delivering telemedicine, and so it’s almost like a virtual medical group or hospital with some IT functions and technology transformation functions. And then there’s a lot of program development, change management, and transformation that we’re pushing across the organization.

Demand for virtual nursing

Gamble:  Really interesting model. You brought up virtual nursing. I can imagine that’s challenging since there is so much demand and so many places that need it. Can that be difficult to determine where it’s a priority?

Cunningham:  The way we look at it is, because Providence is so big, we have the benefit of taking the path of least resistance. Sometimes a business line comes to us and says, ‘we want to do this,’ and we help them with it. And sometimes it’s, ‘we think we should do this based on what’s happening in the industry,’ and so we’ll find a pioneer and move forward.

With virtual nursing, it was very straightforward initially. We found a really great partnership with one of the hospitals in Texas. They were hungry for it and the need was clear. And so, we partnered very closely with our chief nursing officer on that. Once we were able to go in, prove it out, and then demonstrate the value proposition, people pretty much got in line and asked, ‘can I go next?’ Obviously, there are some regulatory and union issues you have to be sensitive to, and so, you want to make sure that you’re strategic with what you determine to be the next spot. We had plenty of folks that got in line.

Then, we evaluated readiness, because you obviously want to make sure that there’s leadership boots on the ground to ensure the implementation is successful. Now, we have a nice queue of implementations for virtual nursing.

We have a couple of different models of how we do it. In some cases, the individual units manage the virtual nurses with their brick-and-mortar nurses. It’s kind of a hybrid model versus some places that employ nurses through our department and provide the virtual nursing component, and then the boots on the ground ones are sort of complimentary to them.

The change management piece

Gamble:  What goes into determining readiness? I imagine there are some key steps there.

Cunningham:  You want to make sure you have executive sponsorship and clinical sponsorship, because you can’t underestimate the change management piece. I feel like a big part of what we do is change. Change management and supporting people through change — especially when people are already experiencing burnout and feeling overwhelmed. You’re trying to get them to do something different that’s going to make life better, but it’s still hard. So, it’s making sure that readiness is there.

It’s also evaluating strategic and financial needs. Is the workflow well-baked? Do you have buy-in from the folks where this is being implemented? All of those things go into play, including technology assessments and making sure you have the right path to scale.

Clinicians & the “TMI problem”

Gamble:  Right. So, let’s talk about MedPearl, which I think is very interesting. Can you start by describing what it is and what it does?

Cunningham:  Sure. Let me start by talking about the problem we’re trying to solve. Clinicians are suffering from a TMI problem: too much information. Medical knowledge doubles every three months. And medical knowledge does not live in the electronic health record. The electronic health record is not clinically intelligent; it doesn’t organize information around clinical context. And then we have piles and piles and piles of patient data accumulating. I’ve been practicing medicine for 20 years, and it is shocking. There are volumes of data and pages and pages of information. It’s so incredibly overwhelming.

Because the EHR is not organized around clinical context, and because we have piles of data for which we’re responsible, there are a lot of inefficiencies that occur. There are missed opportunities; things that aren’t seen or caught. It’s not humanly possible for us to keep up with all of that information. And so what happens is that we have dysfunction in the health system.

Specialist problems

Specifically, the area where MedPearl initially focused was around referrals for specialty care. It’s estimated that 40 to 50 percent of referrals that go to specialists are inappropriate or incomplete.

There are three things that can happen. One, the patient goes to the wrong specialist. And it happened to me recently where a patient was sent to me — waited eight months to see me, but she was supposed to go to endocrine. By the time she saw me, her disease state had become so bad that it was an urgent referral. And that happens all the time.

The second thing that happens is patients get sent to specialists, but they don’t have any workup. Meaning they could have had these labs and imaging studies started on a first line, but they don’t have anything. And so, we have to start from scratch and have multiple visits before we get to a disposition.

The third thing that happens is we see patients who don’t need to be seen. These patients wait for months for an appointment, but when they come in, there’s nothing to do. We send them back to primary care. And it’s not fair to primary care because they’re completely overwhelmed.

“GitHub for doctors”

And so, we developed a platform in which we can create, govern, maintain, and collaborate as a clinician community to create digitally consumable, context-aware clinical content in a no-code environment. It’s basically like a GitHub for doctors. Everything in MedPearl is built by doctors. We take all those PDF documents and sticky notes — all the stuff that’s floating around clinics trying to get us to remember what to do or what the next best action is — and we curated that. We put it into a platform, allowing clinicians to create and govern it, and then publish it into a channel that is integrated with the electronic health record.

This way, when I go into my patient’s chart and I click the MedPearl button, it opens it up and is aware that I’m in the patient’s chart. And when I query what to do with this patient that I think has a pituitary adenoma, it tells me exactly what I should do for the workup, when it’s urgent to go to the endocrinologist, for example, and what I can do to start the patient on first line. It also tells me the labs that have been done on the patient. These are the results. These are the imaging studies that have or have not been done, because it pulls that from the chart and organizes it around the way we think.

We have over 600 guides and algorithms in this library. It constitutes 95 percent of what a primary care clinician does. It’s very comprehensive. And we have over 7,000 clinicians using it at Providence today. We just launched it with an external health system, and we have several more in the pipeline because it’s resonating so well. It meets a very significant need.

Support for frontline clinicians

We have data that demonstrates reduced pajama time or after-hours time for our power users. We have data showing improved EHR efficiency and improved value on referrals, meaning that more appropriate referrals are going to specialists. End users are telling us they feel more confident with the next steps, and they don’t feel like it’s being forced on them.

We developed and designed the solution with a human-centered design approach. We did hundreds of hours in the innovation lab to make sure the technology is being built in a way that makes primary care frontline clinicians feel supported. And that’s why they’re adopting it.

The great thing about the platform is that we don’t have to stop with referrals. Yes, we can build content for inpatient use cases. We can build content for patient facing self-service. We can build content for anything we want, essentially. It empowers us as clinicians because we are responsible for the clinical content. It empowers us to manage and maintain that together as a community.

Democratizing clinical expertise

Gamble:  That’s great. And I really appreciate how you started by describing the problem. That’s so important with any innovation.

Cunningham:  It’s a problem every single health system has. Every public health department, every federally qualified health system, tribal health, rural health — everybody is struggling. With this, we’re democratizing clinical expertise and we’re meeting clinicians where they are.

Within the knowledge base, we have insights on different areas. For example, if you’re in a rural area, you might want to take this extra step, because it could be months before you can get the patient in and it’s a five-hour drive. And we have health equity insights that we weave in as well. Don’t forget that this particular ethnicity could have this allele and it could impact their ability to process this drug.

Insights on nontraditional medicine

We also have insights on integrative medicine. We have a lot of patients who are taking herbs and vitamins and things like that. Well, traditional healthcare text and literature will say there’s no evidence to support that. I get that, but it’s not the way patients behave. So what are my talking points with this patient? And do I die on the hill to convince them to get off Armour Thyroid which is controlling their thyroid disease? Or do I say, ‘listen, there’s not a lot of great evidence, but it seems to be controlling it, so let’s just leave it alone and move on to the next thing.’ It’s practical. We took the wisdom of our clinician community and overlaid it with evidence-based practice. We have talking points from the urologist to tell your patient with blood in their urine who is going to wait four months before they get seen, that these are your chances of having renal cancer. These are the next steps that are probably going to happen. We’re empowering those clinicians to be able to set expectations with patients around those transitions of care between primary care and specialty care.

Gamble:  It clearly addresses a need. And not just from the clinician standpoint, which is obviously critical, but also for patients and caregivers.

Cunningham:  Exactly. That’s why we’re converting the library to patient-facing. We’ve already published the clinician library across Providence with a Microsoft teams integration, which means any caregiver at Providence can access the MedPearl Library. We also have a mobile app that’s clinician-facing, but it’s still helpful for non-clinician; they know what’s going to happen next. It gives them guidance.

The “magic” physicians bring

Gamble:  Absolutely. Another thing I want to talk about is physicians taking on digital leadership roles. It’s something we’re starting to see more of, which is very encouraging. Why is it so important to have that physician perspective with digital initiatives?

Cunningham:  Technology is not the problem right now. There is so much amazing technology out there that can solve so many problems. That’s actually why I left my role as chief medical officer of a medical group. Three years ago, I wasn’t doing anything with technology. I came over to the technology side because people on the frontlines were so frustrated. Doctors were losing it, especially during Covid. All of these things were happening with technology, but none of it resonated with the point of care and with solving problems for the clinicians. And the reason is because clinicians weren’t getting involved. There were very few clinicians. And yet, most of the problems that need to be solved are clinical.

PDFs and sticky notes

With MedPearl, for example, a nonclinical person would never be able to figure out how to solve the problem. They don’t even understand it. When I told my chief technology officer about it, about this problem, I had already built an mvp-bot on a no-code bot-builder that I was testing with a bunch of doctors. My CTO thought I was nuts. He was like, how can this be a problem? How can doctors be dealing with PDF and sticky notes? And I said, this is our life right now. Help us solve this problem.

It is so incredibly important that clinicians are involved. I constantly encourage physicians to do so. There’s a strong desire as well from physicians and clinicians to be involved, because honestly, the only way we’re going to solve these problems is with clinical experts who understand the work, who understand the problems, who live them every day, and partnering with technology experts. That’s where the magic happens; when they come together to solve problems.

Moving forward together

Gamble:  Absolutely. It sounds like it was a priority with MedPearl right from the start to have clinicians involved, and I’m sure it has made a difference.

Cunningham:  It was. It’s a priority with all of our programs. If you look our programs, they’re all very clinical in nature. I talked a little bit about our remote patient monitoring program, but we also have remote therapeutic monitoring and a tele-physical therapy program, for which we’ve completed a successful pilot with two sites. And we’re waiting for the EMR integration before we scale it.

The amazing thing is that it was the PT leaders at Providence who came to me and said, ‘We really want to use this product. We think it’s a great way to extend our capacity and partner together with a digital health solution.’ And so, we did the diligence and evaluation and worked through it. And it’s great.

A lot of times, we have folks from across the different markets who understand what they need and can bring forward solutions. Sometimes we bring things to them, and sometimes they bring stuff to us that seems to be a good match, and we move forward.

Advocating for telehealth

Gamble:  Very interesting. I also wanted to get into some of the advocacy work you’ve done for telehealth. We’ve come to a point where most of us can’t imagine not having that option, but we know there are regulatory issues. Can you talk about some of that?

Cunningham:  Sure. So, 20 percent of our visits at Providence are done virtually. I testified on Capitol Hill early this year because if the reimbursement for telehealth expires at the end of this year, it will create complete chaos across our organization. If we do not continue to have reimbursement for telehealth, it will be a huge, huge problem — both for our clinicians and our patients, especially those in rural areas. They’re going to be impacted the most. And so, it’s really critical for Congress to act. That’s number one.

Number two, there have been a lot of discussions that it’s less expensive for providers to deliver telehealth. For integrated care delivery systems like us, that isn’t the case. Just because I do a virtual visit in my clinic, that doesn’t mean the costs go down. I still need my nurse and my front desk person. If anything, it costs more, because now I have to have technology in place for that.

If they reimburse significantly less for these visits, you are going to disincentivize integrated care delivery systems from actually doing telemedicine, which is terrible. I understand that it might be less expensive for a virtual only company, but that is not what Providence is. And so, I think when Congress is thinking through this, they need to think about how to incentive integrated health care delivery systems to continue to do telehealth. And maybe the ones that are virtual only should be incentivized to be part of an integrated care system. Because for us, it doesn’t reduce the cost of delivering care, but it’s such an important part of patient care. It’s weaved into the daily fabric of what we do.

And I’ve enjoyed being on the speaker circuit. There are a lot of health systems that want to learn from our experience at Providence. They want to hear our story. They want to know how to set things up. Because we’re so large and scaled, we’ve unroofed problems that other health systems might experience in a few years. This way, they can learn from our storytelling and from our experiences.

People often reach out to me to ask, ‘what do you think of this?’ Or they’ll say, ‘we’re evaluating this solution.’ I love being able to provide the wisdom of what we’ve learned at Providence.

Gamble:  That’s so important. And just for clarification, when you said 20 percent of visits at Providence are doing virtually, what kind of numbers are we talking about?

Cunningham:  More than 1.2 million unique patients were served by telehealth at Providence last year.

Gamble:  That’s amazing. I can see why it’s so important. Well, we’re out of time, but I want to thank you so much for your time. It’s been great hearing what your team is doing.

Cunningham:  It’s been a pleasure.

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