In the tenth episode of Telehealth Heroes, we interview Dr. Anthony Dunnigan, Vice President and Chief Medical Information Officer at Valleywise Health. Tune in to discover how Dr. Dunnigan helps his providers as a CMIO, what he thinks about current health technology solutions, and how Valleywise Health went from no telehealth service to over 5000 calls in less than a month.
Episode Transcript
Episode Description: In the tenth episode of Telehealth Heroes, we interview Dr. Anthony Dunnigan, Vice President and Chief Medical Information Officer at Valleywise Health. Tune in to discover how Dr. Dunnigan helps his providers as a CMIO, what he thinks about current health technology solutions, and how Valleywise Health went from no telehealth service to over 5000 calls in less than a month.
Brandon:
On today’s episode, we get to talk to Dr. Anthony again, who is the vice president and chief medical information officer of valley wise, health and Maricopa Maricopa county, Arizona. So Dr. Anthony, welcome to the show today. Great. So you were a practicing physician for many years, and then you moved into informatics and you have a degree in biomedical informatics, which is my degree as well. So this is awesome. We get to talk nerd out on informatics stuff, but I’m curious, how did you make that transition and why did you make that transition from being a physician into more of the informatics space?
Dr. Dunnigan:
Yeah, it’s, it’s fascinating. I know. No, no. Two of us have gotten here the same way in these roles. That’s true, but just I was in the right place at the right time. I was a young resident at the VA when they turned on CPRS back back before most people knew what EMR stood for. So I was one of the guys who would be on call, do an internal medicine call late at night and playing around with, you know, just enough mums code to be a little dangerous and, and pulling into vitals. This is amazing. And plus people can re read my notes, you know, they don’t have to read my scrawl and they can get it from anywhere. So I was pretty passionate about the power of that very early technology at an early stage in my career, sort of a big building. Of course, now we have board certification and everything. So that really lit the fire for me. And I just I’ve had opportunities to kind of deepen my knowledge and get into various technology implementation. And it’s around today.
Brandon:
Were you already kind of a computer nerd before you started tinkered with, with mumps and the VA EMR?
Dr. Dunnigan:
I would say so. I, in college, I was a demonstrator of the apple Newton, which if people remember that it’s a long ago, predecessor to the iPhone, I think I sold one of them in a year and a half, but I would sit there, you know, while people trying to pull people in, then it had very basic handwriting. Yeah, for sure.
Brandon:
Right. Right. And that’s, that’s what it takes. The joke is that I have a background in genetics and then informatics. And so the joke is I’m both a geek and a nerd and that’s, I think that a lot of us informatics can say that as well. So right now, do you still see patients today or are you truly focused on the it side of things? I do.
Dr. Dunnigan:
It keeps me honest and humble. I work with the internal medicine residents. So I, you know, I get in there and use our EMR and teach them really, you know, probably my strength is, is teaching the young learners apology, whether it’s voice recognition stuff or telehealth, you know, basic EMR to tillage that they get some of that now in medical school. I think people that come through fairly adept at, at ticking them argue. So it’s fun to now kind of get them up to the next level with some of these tools,
Brandon:
Right. They’re all trending news on Facebook and Snapchat. And so getting them to document stuff in, you know, an EHR is not that much more to do
Brandon:
Right. So what is, what are some of the biggest challenges you face as a chief medical information officer with regards to managing data or connecting with patients that, that you, you struggle and, and, and face every day?
Dr. Dunnigan:
Well, you know, it’s funny, so some of the challenges remain over a decade and a half and informatics, you know, I I’d say we have a very good tall of the EMR and intercept work hard on usability, the human that work at some of the vendors and, you know, they’re making it, they’re trying to make it easier to reduce clicks, reduce scrolling. And, and I’m very thankful to that. And, and, and those, you know, when they roll out those upgrades, they play with basic usability, remains a concern cheesy program. We’re trying to get people out the door and get them home to be with their families and not turn their computer on at 10 o’clock at night and finished charting. And so, oh,
Brandon:
So we’d say efficiency for the providers and documentation and stuff
Dr. Dunnigan:
That, that remains near the top of the list. You know, if you look at physician burnout, which is of course a huge problem and has only intensified during the pandemic, you know, three of the four top causes of burnout are technology-related. So we try to address those.
Brandon:
Tell us a little bit about valley wise health and the patients and the population that you care for.
Dr. Dunnigan:
The Valley’s huge. So if you’ve been to Phoenix and Maricopa county, you know, it’s an hour out in any direction, very diverse population, it’s a safety net system. We, okay. It’s a large chunk of our business. I’d say upwards to 60%. We have a lot of patients that, that are, that are cash paying without insurance, you know, a smaller book of business of Medicare and private insurance at the very diverse population, many, many, many patients whose first language is not English. We have a lot of grants, so it’s, it’s an amazing environment. It, you know, it’s an incredible mission. It’s a great teaching hospital, you know, passionate for years about getting technology in the hands of Denise, even with all those caveats, right? So things like the patient portal, the personal health record, and this was another one. And I, you know, in those first days where we were spinning this out, we were very cognizant of, of how are our patients, how are we going to, it’s got a separate, I’ll pull things. And there’s honestly going to have to be some facilitation and warm communication there.
Brandon:
Right. So let’s talk about your involvement, an introduction to telehealth. Have you been doing tele-health previous to COVID or is this something that came more recent for you?
Dr. Dunnigan:
Yeah, we had been discussing tele-health for years. We certainly as a county safety net health system and, you know, other parts of Arizona, our specialty care. So the benefits of all the health in the state are, are huge up north in north, by staff area, which is actually the second largest county in the U S by land. They’ve been doing oral health for 20 years. So we’ve been, we’ve been trying to get this off the ground. I think probably early thinking was it was, it was a fairly heavy handed, you know, heavy technology play. We we’ve been trying to figure out the middleware piece, you know, how do you connect one system there? And so we’d had a lot of those conversations for years and years and had been working to spin up some pilots and I’d say we were sort of dabbling in it. Right.
Brandon:
And then, and then COVID hit and that’s what really prompted you to, alright, we got to really figure this out and do something. What was that experience like?
Dr. Dunnigan:
I’ve never seen anything like it in my entire career. Everything changed since March 17th, 2020, I’m gonna St. Patrick’s day when the, the office of civil rights sent out that now infamous memo basically saying, Hey, you, you can use telehealth. You can use just about anything. You can FaceTime. You can Skype Facebook messenger and whatever you have best five. You shouldn’t use like tick talk. They actually called that. But, you know, it was pretty much all fair game. And you were going to get full per diem for a, for a typical, you know, you know, level office visit. And that literally changed, you know, the, the business rules changing overnight fire in that same memo, there were a shortlist of sort of semi sanctions. Of course it was one of them. Right, right. So that, you know, within, I’d say matter of four to six hours that day in place.
Brandon:
Oh, that’s amazing. And that’s a big thing. Cause a lot of the hesitation pre COVID was this, this complicated to use got to make sure stuff is HIPAA compliant, but also we’re going to do all this work and have this huge capital investment to have this expensive telemedicine system. And then we’re not even sure we’re going to get paid for. So there’s just high levels of very entry, little amount of rewards for a lot of the larger health systems. And overnight that, that flipped like this easier to get in, just do whatever you can use and you will get paid for it. And now that the, the economics of it completely changed overnight.
Dr. Dunnigan:
That’s exactly right. I always think of that. It’s a three legged stool technology operations in business, most, if not all of the technology, right? The business rules, as you say, were very cumbersome, convoluted, hard to understand some of the codes were opened somewhere and, you know, met Medicare, Medicaid, private payers all had a different take. And then honestly, we didn’t have a huge operational poll. There was a lot of interest and, and sort of some pet projects I’d say, but suddenly overnight, you know, the business side became dramatically simplified. And we had a huge operational pole. You know, those first 24 to 48 hours, we had a desperate need to deliver care to people in their homes, keep, keep people with conditions. But the system right, ask me for patients that had symptoms out there. I’m more concerned about COVID. So it was really an immediate congruence of those three things.
Brandon:
So as you were rolling out telemedicine to your organization, what was that experience like?
Dr. Dunnigan:
Yeah, those first few days we got a few people doing pilots at the platform. I tried to pick people in various spaces, some ambulatory docs, primary care, specialty care. We looked at a few use cases on the inpatient side and the experience was incredibly positive. And in fact, it’s one of those rare times in my career where word of mouth was so strong that, that we had people asking why I didn’t include them in the pilot 48 hours after, you know, getting a few people in. So, and I think it was smart to bring, to have a various set of folks, you know, family, doc, internal med pediatrician, OB clinic, some of the surgical subspecialties. So I, I think at that 16% principle, you’ve probably heard that if you can get 16% of folks engaged in something and to buy in, you’ll sort of get that inflection curve going in the right way. So the ramp up was incredible. I I’ve I’ve, I’ve got a graph of it. It’s I’ve never seen anything like it in my career. I mean, and you know, to think a year and a half later going from zero to 250,000 visits, obviously we’ve, we’ve, we’ve, we’ve now got a steady state going, but those first I’d say four to six weeks it as a CMIO. It’s it’s an adoption curve I dream about.
Brandon:
Oh yeah. I bet we, we can relate. So how satisfied are your patients and providers in this change and movement into telehealth
Dr. Dunnigan:
Concerned about that? But you know, as a technology we’ve been trying to get off the ground for years, obviously we want to, we wanted it to work. Well, ideally, certainly the first few months we actually did a very early survey back when we were utilizing the free version of doxy, since it was April of 2020. So we surveyed patients and we surveyed providers with the help of our marketing department. And even, even using the free version, a lot of providers were still using their own phones. The patients were using whatever they had at their initial problems. The satisfaction was very high. And one of the questions I love to ask is if, when the pandemic ends, which you like to continue using this technology, and it was like 90%. Yes. I mean, again, awesome. Just numbers. I don’t see, you know, I, we asked people, we do surveys as part of our efficiency program about EMR usage and other things you don’t see those numbers. So we knew we were heading in the right direction, very early with both our patients and our providers.
Brandon:
As you were looking at the, considering your patient population and who are you, you were serving and looking at the available technologies. What, what, what is it that factored into your decision-making?
Dr. Dunnigan:
Yeah, we had video conferencing tools. We’ve got through seven means. Honestly, they were just very cumbersome. There’s an administrative burden. You know, part of my job is to work with my colleagues or employees and get those things working in it. And that’s that’s work, you know, and that’s our, that’s our staff and that’s my physician colleagues. So we gave that we, we released a technology, has to be very simple, to use very intuitive. It would be very little training, highly scalable that it took, you know, it took almost no thinking to get off the ground. And so we started looking at a few of those technologies and of course we looked at doxy and, and that sort of checked all the boxes. And that’s that, that principle, that concept has remained very true today if iterative things and coming out of the tactical place into a more strategic place, that principle is still as important today as it was back in March of 2020.
Brandon:
And it sounds like simplicity is a, is an underlying thread through everything you’re looking at. So when you’re looking at EHR is how do we simplify that? And you appreciate, and you value that usability aspect. That was the decision factor in your telemedicine app. It sounds like those are the things that, that you are, that, that are important to you that you value the most.
Dr. Dunnigan:
Absolutely. You know, you think how complicated the EMR is, right. I mean, it’s a common analogy is the cockpit of a 7 47. And in the past we we’ve looked at, you know, how do we, how do you bring in middleware and integrated into the EMR? And there’s no ways you can do that. And there’s apps out there and all that with the time we had, we, we, we didn’t worry about any of that. So we, we brought along a platform alongside the EMR thinking in the EMR that the documentations scheduling all the billing components, we left that as is and stood this up right. Alongside it. And, and I think that really get this going quickly, very rapidly, to be honest.
What are some of the challenges in usability that you and your organization are facing today that you’re looking to, to fix or address sort of simplify it for more?
Dr. Dunnigan:
Yeah, I think that on two fronts, so the, on the healthcare side technology plays not just the EMR, but we’ll send, I think it’s perfect for somebody who manages a team of informaticians better understood. Infomatics like we do today. You know, when my parents ask me, what the heck is this informatics thing you do? I think people get it now, right? It’s, it’s, it’s technology with workflows. And just making things flow in a way where you don’t have to have five neurons fire to make something work. You can, you can dedicate that brain power to healthcare. So, and then the flip side patient experience, you know, we certainly had a good glimpse of that as we cause we really pushed to get the personal health record more widely adopted, and we had success there. But as, as we, and found the devices that the patients had, it was that experience all over again. And you hear the term digital applied right with what our patients have is what their technical maturity capabilities are. And we really cater to that. And it’s a wide spectrum. I mean, I’m often w we’ve got homeless patients that are very savvy with smartphones. So I try not to make any assumptions, you know, when people come in the door or when we’re talking to them on the phone,
Brandon:
Oh, I’d like to like dive in a little bit more on this. So what are some of the, what are the patient challenges that you’ve seen in rolling out telemedicine and other technologies to patients?
Dr. Dunnigan:
You know, it’s, I think back to when we first started buying airline tickets online, or you go up to a kiosk and you remember the first couple of times, you’re like, I just don’t trust the staff. I’m going to go up to the gate, somebody. And then there was a day where the person, this would be a lot easier for you. If you just use this kiosk over here. I think it’s really getting more visits. And it’s not just on the patient’s side, it’s on the provider site too. So I told all of my colleagues and I still do like, you know, look, just get this thing up and running. You’ve got a lot of people here to help facilitate the experience by the time you’re two or three calls in, you’ll be a pro. And by and large, it’s true. You know, once you, once you get the camera working and you get the settings configured, right. You know, people are just rocketing, both providers and patients through those first faith. Right. Once you, once you leave it’ll work and you can rely now we’re offering. So,
Brandon:
Right, right. Yeah. You’ve got to take that leap of faith. And once you show that you can do it, like, all right, I got
Dr. Dunnigan:
It actually does work. Wow. This is great. Yeah.
Brandon:
And, and how do you see the attitudes towards telemedicine and technology change as doctors and patients get more used to this?
Dr. Dunnigan:
It was perfect. It was such a poll and people were quite famous tech to get this technical right. To how to work. And B do we be efficient and easy and, and, you know, on both sides and, you know, you had these one to weeks in, we have these rich stories, you know, providers looking into the homes of family members and they’re looking into what’s in their fridges and meeting family members. Yeah. Yeah. So the satisfaction was huge early. And so we really just so you know, the word the last half has been largely, you know, how do we take advantage of this? We know it’s never going away. How do we continue to, to be better? How do we leverage tele-health and coordinate that more tightly with in-person care? You know, there’s things you need to come in for it. You need to come in for shop and pick up. So that’s the right balance there. And that difference across the service line, we’ve, we’ve really wrote accurately waiting to get to a, a pretty savvy, which just is remarkable.
Brandon:
Well, let’s talk about that. Cause, you know, before COVID, most of the healthcare industry was over on this other side, not using tele-medicine to all COVID hit, swung to the other side and they were all of a sudden, all exclusively telemedicine. Now it’s kind of coming back and, and what is that final resting point? Could it be, what is healthcare gonna look like in the new, what is the new normal of healthcare?
Dr. Dunnigan:
It’s a great question. And I think, you know, by 25, 30, 30 5%, we know a significant bulk of business is just perfect for telehealth as long that ratio quite dramatically over the last year and a half, you know, here in the Phoenix area, we’ve had a couple of these horrible waves. Of course people saw that on the news. So, you know, we, we swung it back up to 50, 60% at times we think some would need it when needed yeah. Purpose. Right, right, right. We think somewhere between 25 and 35% is probably the sweet spot. Again, it’ll differ by service line. I mean, there’s services, you get a thorough in-person visit with certain things and you could probably have two or three telehealth visits after that. So a lot of our strategic work that’s ongoing cause is to really find that sweet spot.
Brandon:
What are some of the challenges that you foresee in the future in adapting to this new normal that still need to be overcome and addressed?
Dr. Dunnigan:
Yeah. We’re aware that streaming screening rates are down immunization rates are down. So we talked about trying to find the ideal way to connect telehealth and in-person care. We’re we’re still working on that as I know everybody is. So we’re, we’re getting a little bit more structured around which type of visits we promote in-person which your ideal for tele-health, that’s a huge piece of that strategic work. The tele facilitation continues to mature things like translators. So a lot of our visits would require a translator. We’ve now got a nice system in place where the translator can get on doxy as part of a group visit. We’re working with our third party vendors that help us with translation to be able to do some of that as well. And then, you know, the rules continue to change. We’re working really closely with the governor’s office here in Arizona, to understand sort of where that vector’s going, you know, does, is this a patient need to be in the state as the provider need to be in state some of those ramifications.
Dr. Dunnigan:
So I think there’s, there’s a lot of that work ahead. And then probably the biggest thing is ensuring that, you know, this incredible new mode of care that we feel will never go away, making sure we match that to quality. And, and we’re doing some research and there’s a lot of research nationally now on, on exactly that, you know, how do we take advantage of this technology, pair it in the right way with in-person care and, and follow metrics, you know, to me, this permanent satisfaction, this promotes engagement, I think we’ll see higher quality because of that. I think those are, you know, diabetes care, blood pressure control. You know, I th I can think of a whole host of metrics that sort of equate to engagement. I mean, this is an engagement platform and it’s, it’s an incredible one. So I think we’ll see that bear out. I suspect there’ll be probably another year or two before we see that
Brandon:
Really the keyword there’s engagement. So you know, how well our patients engaged and, you know, some patients now that they’ve tasted the convenience of telemedicine are going to question, do I really need to come into the in-person clinic for this? And, and, and we’ve heard stories of patients just not going to in-person visits because it’s just too hard to take time off work, to travel to, especially if they don’t have a vehicle or to, to take a boss or whatever. But, but the ability just to have the ability to see a provider by a video increases that access and engagement with that patient, that they otherwise would have skipped because it was too complicated.
Dr. Dunnigan:
Absolutely. That that’s crucial part of this. And, and it’s our job to help patients navigate. Right? I mean, I tell folks all the time, you know, coming in person and navigating our healthcare system is not easy. I mean, I get lost on campus. And so, you know, we love the notion of, of tele-health as being an easier way to get care. It takes some navigation though. And so when, when folks call w we’re working really closely with our patient access center to be able to offer them the right type of visit for the right thing, I was trying to get my son into a dermatologist and they were like, do you think this could be done via telehealth? I’m like, heck yeah, I’ve got a camera here. So I’m in the same boat, you know? So that’s a, that’s a crucial point though, on engagement.
Brandon:
How has your perspective of healthcare changed through this experience?
Dr. Dunnigan:
Well, great question. I, this is probably the perfect example and it’s a lot of what I talk about with our senior executives. And I’ve given quite a number of talks. You know, it comes back to that alignment. You know, we finally had alignment of a technology with an operational drive with a clear business layer. It was just a home run. So, you know, we’re starting to look at some other things now, you know, another thing we’ve been trying to get off the ground for a while are eConsults the inner, inner, inner professional consults. You know, I might see you in my primary care clinic and refer you to a derm doctor, without you even seeing the Durham doctor, you can get a, you get a asynchronous consult. There’s a huge role for that. And again, finally, we have some alignment and we’ve got a clear business understanding a lot of the extended care team. I think of care coordinators, case managers, other folks doing population health work, you know, the team that surrounds the provider. Some of that’s become clear and more aligned as, as we’ve been through this pandemic. So, you know, I talk a lot to my operational folks and I, sometimes I take the technology out of things and it’s just, you know, what am I trying to do? What’s what’s the business model for it? How do we scale it? This is, this has been in some ways a blueprint for that.
Brandon:
Right. Right.
Brandon:
Oh, that’s fantastic. I love to hear those things. Well, Dr. Anthony Dunnigan, thank you so much for your time today,
Dr. Dunnigan:
Brandon. Thank you. It’s a privilege to be able to share some of our story. Great talking to you. Appreciate it.
