Healthcare 2040:Tech, Innovation and the Future of the Healthcare Workforce

Steven Collens:
Hello, everyone. Welcome to Healthcare 2040. It's a series that MATTER produces together with Baxter. I'm Steven Collins, I'm the CEO of MATTER. We are a healthcare technology incubator and innovation hub with a mission to accelerate the pace of change of healthcare. We do three things in service of our mission. First, we incubate startups. So we launched about seven years ago. We've worked with more than 700 companies ranging from very early to growth stage startups, and we have a suite of services to help them at every stage of development. Our member companies have raised more than $2 billion to fuel their growth.

Steven Collens:
Second, we work with big organizations, health systems, life sciences companies, payers, to strengthen their innovation capacity. We help them find value in emerging technology solutions, unlock the full potential of their internal innovators and create a more human-centered healthcare experience through system-level collaborations.

Steven Collens:
Third, we are a nexus for people who are passionate about healthcare innovation. We bring people together to be inspired, to learn, to connect with each other. We produce a lot of programs, including large scale events for the broader community, such as this one, as well as small forums that are exclusively for our members.

Steven Collens:
Today's program is part of our Healthcare 2040 series, where we look at what healthcare might look like in 20 years and how we're going to get there. We have a great collaboration with Baxter to produce this series. Baxter is a Chicago-based company that has evolved and currently has a focus on connected care, on earlier diagnosis, on workflow management and a variety of tech enabled healthcare innovations.

Steven Collens:
The topic of today's conversation is technology, innovation and the future of the healthcare workforce, and we are fortunate to be joined by Joel Ray and David Chou. Joel is VP of patient care services and the chief nursing officer at UNC REX Healthcare, a health system in North Carolina. He oversees more than 2000 nurses and other healthcare professionals. David Chou is the chief information officer at Legacy Community Health, a federally qualified health center with 50 clinics in Southeast Texas. David is also one of the most mentioned CIOs in the media. Our moderator today is Dr. Carlos Urrea, who's VP of medical affairs at Baxter. Dr. Urrea provides medical oversight for evidence generation and dissemination activities and guidance and product development pipeline and digital health strategy. So Joel is going to kick us off with an overview of the staffing situation and what the implications are for the future. Joel.

Joel Ray:
Thank you, Steven. It's my pleasure to be with you and discuss this very important topic. So let's go ahead and jump right into it. Although we are experiencing an unparalleled nursing shortage, the phenomena it's happening here in the United States and in other parts of the world, at it's basic element is simply a gap of supply and demand. It's a multifaceted problem and aspects of this challenge have been well documented for over 20 years. Yet the COVID-19 pandemic seems to have exacerbated these challenges in a way that I think few of us expected this level of disruption. So before we explore these factors, let's take a moment and look at the actual size of the shortage. Next slide, please.

Joel Ray:
Estimates often vary widely around a shortage and no one has a crystal ball as to exactly what the shortage of nurses is going to be at the bedside, but there are some things that we can look into. The Bureau of Labor Statistics reported in May 2020, that there were about 3.1 million nurses working in the United States, about 61% of those were working in the hospital setting. Over the next decade, 2020 to 2030, that nurse scheme workforce was projected to grow by about 9% to 3.4 million. But during this same decade, year over year, there was going to be an additional demand of almost 195,000 nurses each year. So pre-pandemic projections were reporting as much as a 510,000 RN shortage RN workforce across the United States.

Joel Ray:
Then suddenly 2021 came along and already 33 states were reporting that at least 20% of our hospitals were experiencing critical shortages. Here in North Carolina, our shortage is going to range between 17 and 32% all the way out to 2033. And the challenges can be unique, different in terms of metropolitan areas versus rural areas. Here in Raleigh, we're a rapidly growing community and that's promoting our increased demand for nurses, but many rural parts of the country experience an increased demand because as nurses graduate, they often gravitate to academic medical centers and to metropolitan areas where the pay and opportunities are viewed to be better. Next slide.

Joel Ray:
So as we think about some of these old pressures that have not gone away, we've known for a while that we have an aging population of Americans, and by 2030, one in every five Americans will be a senior citizen. And these senior citizens are now living with multiple comorbidities, multiple diseases that are increasingly survivable, but really require a lot of care and support, and that's increasing our demand for nurses.

Joel Ray:
And then the nursing profession is experiencing great opportunities in terms of expanded scope. Nurses have the opportunity to take primary care more into rural and community settings. Nurses are very equipped with our holistic training in order to be an important part of healthcare reform, helping make healthcare better, faster, more affordable, and more accessible. But these are creating new positions and frequently those are outside the hospital setting. And then of course, universal healthcare, the Affordable Care Act bought about 20 million additional Americans into better access to healthcare, and that's also driving up our demand.

Joel Ray:
So just like those issues on the demand side of the equation, the supply side of the challenge, many of these issues are not new either. Our nursing workforce continues to have an ever increasing workload. Healthcare nursing, we're one of the most regulated industries in the country. And so it seems that we keep adding to the work that we require nurses to do without really being able to take anything away. And that's increased the strain that our nurses have reported across the years. And then nursing is a very physically strenuous job. Our nurses are frequently working on their feet, 12 hours a day, and then it involves a lot of physical lifting and movement of patients that sometimes causes injury, and a number of nurses leave the profession each year, regrettably because of experiencing injuries in the workplace.

Joel Ray:
And then just as the US population is aging, so is our nursing workforce. Almost half of us now are over the age of 50 and there are over a million nurses projected to retire before 2030. So that certainly creates not only an addition to the shortage, but it significantly diminishes the amount of experience and knowledge in the profession and rebuilding a nursing workforce takes time. And one of the challenges that we're experiencing is our academic facilities don't have the faculty that they need to take all applicants into the nursing programs. In 2020, over 80,000 qualified applicants were not accepted because of lack of faculty positions in order to take that volume of students on. Next slide.

Joel Ray:
So those are some of the challenges that we've been experiencing for a couple of decades. So why is the shortage so different now? Since 2020, the healthcare sector as a whole has lost over 500,000 coworkers. Nearly half of the nurses in the United States now report that they're at least somewhat likely to leave the nursing profession over the next two years, and 95% of the hospitals in the country now see and view retention as a strategic imperative.

Joel Ray:
So how has all this happened? I personally think of it as the tale of two tsunamis. That first tsunami being the COVID-19 pandemic and the volumes of patients that it brought into our healthcare systems, at times overwhelming us, certainly challenging us and increasing the stress in our work environment, not only because of the volume of the patients, but when you think early on, we didn't know if we had enough personal protective equipment or masks for all of our caregivers and our nurses and others were wearing their masks for several days, and in some instances in the country, a couple of weeks before they could be confident that those masks could be replenished. And then we were dealing with constantly changing guidelines from the CDC as to how to best protect our teammates and our patients. And that certainly added to the stress of the work environment that we were seeing.

Joel Ray:
I think the other thing that we've seen over the course of the pandemic is as there's been this polarization around the virus itself and the vaccine treatment for it, and we've seen an American public that's grown increasingly agitated and frustrated and angry. And just if you've seen so many issues in the airline industry where there's been so much workplace violence there, that has been a significant challenge that we're also seeing within our hospitals as well.

Joel Ray:
The other piece in terms of that second tsunami is that right after the COVID-19 pandemic was declared to be a national emergency, what we saw is a rapid drop in volumes all across our country for non-COVID care. Really the first issue was that many of our hospitals across the country stopped non emergent and urgent procedures so that we could conserve our PPE and so that we could begin to train our staff for the challenges that were ahead of us. So we began to see not only those reductions, but even the 42% reduction in emergency department use to include patients coming forward for life saving treatment.

Joel Ray:
So it became apparent to us that what we were really beginning to deal with was at an American public that was increasingly afraid of seeking out healthcare because of their risk of getting the virus. And as that happened then what we began to see was that second tsunami of patients who, they were not COVID, we call them NOVID patients, but they had very serious disease processes that had gone unattended for an extended period of time, and now they were coming in very critically ill. So we were now getting these waves of COVID patients and NOVID patients at the same time, and our ICU demand for beds in some instances was doubling and tripling, and so we were having to pair critical care nurses with acute care nurses so that we could expand our volume of patients and our volume of ICU capability. And that again, added to a very high stress environment that we were experiencing. Next slide.

Joel Ray:
It's truly hard to explain the level of physical and emotional exhaustion that is prevalent across our hospitals today. Early on in the pandemic, we thought we were gearing up for a very hard sprint. And what we found ourselves dealing with was a multi-year marathon in which we don't really know where the finish line is going to be. Early on in the pandemic, there was enormous amounts of support from restaurants and businesses, bringing snacks and meals to our teammates and drawing caricatures on our sidewalks of them being heroes. But over time, as we went through the pandemic, what we found is that more of those institutions were actually finding their selves struggling for their own survival, and so our workforce began to feel increasingly isolated and less community support. And then as I mentioned previously, as that tension around the virus and the pandemic increased, and our society was increasingly polarized, we have began to see a lot more workplace violence in our hospitals across the country.

Joel Ray:
As a matter of fact, nurses that are taking care of COVID patients find themselves actually twice as likely to be assaulted or abused as those taking care of non-COVID patients. And this has caused a tremendous amount of burnout in our organizations and we have seen as much as a 25% increase in turnover in many parts of the country. Our nurses were seeing increased days of call outs because they're dealing with their own issues. And then I think another important piece to remember is that our nurses are people just like everyone else, and they're dealing with what has been called the second shift of stress, when they go home now to significant others, who's lost their jobs, to schools that have gone virtual and daycare that are closed, and they're having to deal with all of those stresses. And it's really created a 24/7 high stress environment for many of our nurses and healthcare workers, and that's been a significant part of the challenge that we've experienced. Next slide please.

Joel Ray:
So as we think about the consequences and the nursing shortage that we're experiencing, we can't really look at it in isolation. Not only are we seeing shortages in nursing, but in many of those support areas, our housekeeping, our nutrition and food service, our nursing assistants, our transporters, all of these frontline positions and care partners are experiencing shortages. And frequently, because the nurse is the last bastion of safety and care delivery, those roles are picked up by the nurse because they want to make sure that they're doing the very best for our patients.

Joel Ray:
And then the next piece of challenge that we've seen is that we're seeing a decline in clinical indicators and clinical outcomes. And of course, our nursing team and our healthcare teams, they've all entered this profession in order to support and help the wellbeing of our patients. So as we see that experience and clinical outcomes decline, that is very discouraging to our folks as well, and is a source of incredible stress. So as we think about how to move forward, typically when you have a supply demand issue, it's about better forecasting and better production, but I think the challenges are more significant than that. And this is where we need that partnership with technology on ways that we can potentially change and address this gap through a better partnership. Next slide please.

Joel Ray:
So that causes us to think about the future and where we're going to be in 2040 and how we need to look at our workforce differently. What are the operational and organizational changes that we need to make, and how do we partner with technology in order to help close this gap in maybe a non-traditional way? I think that we can be positive about the future. We're a very creative country, a very energized and focused healthcare system. And I think that together we can pivot and do the next right thing in order to help us to create a future that is bright for healthcare and bright for our workforce to help us manage through the backside of this pandemic. Thank you for allowing me, Steven, to make these comments and I'll turn it back over to you.

Steven Collens:
Thanks so much, Joel. It was a great summation. It was fascinating. It was a little depressing, but very helpful. David, I'll turn it over to you. David's going to provide an overlay to that around technology and innovation from his perspective. David, thanks very much.

David Chou:
Thanks, Steven. So I'm just going to provide a macro level of the trends in healthcare, the tech trends, and then some of the growth strategies. So if you just take a look at this chart. Joel had mentioned high growth, lots of mergers and acquisitions that you have seen the last 10 years, but what's surprising is that, as you can see in this chart, the number of mergers and acquisitions are actually declining, but what's happening is the deal size of these mergers and acquisitions are getting bigger and bigger. So you're starting to see what we are calling the mega mergers. You're starting to see organizations that traditionally would not have partnered with each other five to 10 years ago, and now they're creating alliances, they're creating entities together, and that's really a theme that we're seeing in healthcare. It does not help with the burnout and some of the staffing challenges because this still really impacts the fact that patient care continues. But this is a macro trend that we're starting to see on a healthcare level. Next slide please.

David Chou:
And here are some of the tech trends. Obviously, I won't touch on every single one of them, but everyone's aware of some of these technology solutions that may help with burnout, but also may not help with burnout. Throwing technology at a problem doesn't always mean you're going to get more efficiencies, but we're hopeful that tools like clinical communications, which is something that's prominent at every institution nowadays, we're hoping to have a lot, lot more uses of AI to really provide better care, but also provide better insights to that, so our clinicians can't really focus on care. So these are some of the macro trends that we're seeing. Happy to share these after the slide. I mean after the panel. Next slide please.

David Chou:
And then when we think about growth, this is something every organization is thinking about. How do you grow effectively? Here are some of the six success factors. Obviously, providing clear guidance in terms of value creation and a clear identity is going to be huge. Got to have a good successful go to market formula. You must have the appropriate structure based on your geographical footprint. We talk about agility a lot. Is your operating model agile? Can you change your operating model and tweak it in a matter of months versus years? And then of course, you can't talk about having great growth without effective talent system. So that also comes in line with what Joel mentioned earlier about just staff retention, having the right talent at the right place.

David Chou:
And then lastly, you got to have the right regulatory and policy structure to support the growth. If you're not going to get paid appropriately, you can't grow appropriately to be able to fund those initiatives. So these are some of the three main macro trends, as I'm calling it, that we're seeing in the healthcare factor, but I'm looking forward to our discussion. So let me turn it over back to you, Steven.

Steven Collens:
Great. Thank you so much, David. Really appreciate it. Carlos, I'll bring you in and look forward to the conversation that you're going to lead together with Joel and David. Thanks so much.

Dr. Carlos Urrea:
Thank you, Steve, and good afternoon. Good morning to our audience. And Joel and David, thank you so much for accepting this invitation. It's always a pleasure to have you here and thank you so much for that very interesting, and as Steve said, maybe a little depressing conversation, but that is the reality that we're looking at today. Joel, let me start with you and let's say maybe at a macro level, when we look at the trends, you showed us how these trends are really pointing to this continued shortage, but are you aware what's going on at a policy level, regional level, private level as to what actions are being taken to try to revert this trend? And thinking on the theme of 2040, what do we think that's going to look like 20 years from now?

Joel Ray:
Thank you, Carlos. I think we are beginning to look at how do we restructure our clinical workforce, not only to include our nurses, but to include our overall care team. As we were talking about, we keep adding to the nurses' plates. I think we've got to look and continue this movement towards every individual practicing at the top of their license and augmenting our care teams with non-licensed, non-certified people when it doesn't require that in order to do a certain role. And I think a lot of times our nurses end up picking up a lot of those responsibilities that they really don't have to be licensed for. So I think that's some of the shifting that we're going to do.

Joel Ray:
And then the other piece is I think, especially as we think about the drain on the workforce, in terms of the physical taxing nature of nursing, I think we have real opportunity with virtual capability that's being added to bring in virtual partners to support our inpatient teams, looking at what is it that a nurse can do virtually to support care? And I've heard it described and we're working through it here at UNC REX is anything that a nurse can do at the bedside with their hands in their pockets is something that a virtual nurse could do. So we're beginning to build our systems around that kind of support as we think about the future.

Dr. Carlos Urrea:
Awesome. And we're going to get into that virtual nurse and that support in a little bit. David, needless to say technology is vital for innovation and efficiency within the healthcare system, within the workflow, lots of investment, lots of things happening at that level. From a chief information officer perspective, what can technology do better to support your health system and specifically the staff?

David Chou:
Maybe it's a twofold. I'm not sure it's not technology can do better. I think if you look at some of the operating models, it has to tweak to fit some of the technology solutions. You cannot fit in a modern technology without tweaking your operating model. So let me give you prime example. Maybe I won't even use nursing or clinical. I'll just use something as simple as supply chain. Everyone talks about how they want to be like an Amazon who has one of the best supply chain, or UPS. But if you look at the healthcare supply chain operating model is probably the same operating model that has been existing for the last 15 years. So no tweaks have really happened there in terms of modernizing that model, but everyone just thinks, "Oh, I want to be like a retail supply chain." Well guess what, probably need to tweak some of your operating model.

David Chou:
The same goes for care. You have latest and greatest technology, but the care may need to be tweaked a little bit. How we learn and practice medicine five to eight years ago in medical school or longer may not be applicable today. So I think that piece is hard and that piece may not be discussed as much, but I would say that's something that organizations need to tweak about. And on the flip side, when I look at some of the solutions that comes in play, there's also a component that's missing where the technology product or offerings that's provided on market, they may not know the hospital business or even the inventory business really well. So you have a gap right there between both sides to where we're not finding that common ground. So I would say hopefully we make better progress, but that's some of the things I'm seeing in the industry to where the technology doesn't get to where it needs to be in terms of the vision. And at the same time, the users are not feeling the impact of having these latest and greatest solutions either.

Dr. Carlos Urrea:
Thank you, David. So I'm pull on that thread, like use that example of how the care needs to change as well. And Joel, you said the same thing when we're thinking about how do we support nurse differently? So one example will be telehealth. Telehealth was always viewed as a, "I'm going to take care of the patients remotely outside of the hospital," but we've seen a very interesting trend about telehealth where you're supporting care remotely, but within the hospital. So Joel, maybe I'll start with you. What are you seeing in terms of these telehealth within the hospital? What is your experience? What trends are you seeing in that space?

Joel Ray:
Well, I think what is interesting is we made some real advancements because we had to, during, during the COVID-19 pandemic, we really weren't using much telehealth, any internally at all. But we found that when our patients and families were not allowed to be together because of the risk of spread of the virus, we got very good very quickly at linking and connecting our patients and families together. That then has resulted in really taking that to the next level and connecting some of our providers who were able to visit their patients virtually so that they weren't having to be exposed, so we didn't run the risk of contaminating our own staff as they cared for patients that helped us preserve a limited provider pool. And now we're really looking at how we can do that with our nursing teams.

Joel Ray:
And you're always going to have to have a nurse at the bedside, but there are many things that we can do to support that nurse with a virtual nurse and doing so, helping with that admission process, that discharge process. A lot of those elements will take 30 to 45 minutes per patient, and when you're trying to take care of five or six patients, that kind of honing in for one patient is very time consuming. That virtual nurse can partner with that acute care nurse and together accomplish that care. I think we're going to find that there's a lot more opportunity that we can do as we expand this, and we're just launching it. It's still very new to us, but we're definitely moving forward rapidly in that direction.

Dr. Carlos Urrea:
Thank you, Joel. David, what does that mean from a chief information officer, the technology, the infrastructure? What are your thoughts into this telehealth within the hospital type of world?

David Chou:
Well, I think it's great. I think we're finally starting to adopt it. I will also add to that comment of COVID making the acceleration towards digital. I think the other piece is it's not really COVID, it's just organizations accepted that their process is broken. They're just going to bypass and get things done. So COVID did really help with that piece as well. But the other side is I'm also seeing a trend shifting back to where the number of telehealth visits are decreasing, unfortunately.

David Chou:
But from my perspective where I sit, I think it is part of care. Telehealth should not be a separate thing. It should not be a differentiator anymore because it is how you provide care. Let me give you an example. Everyone has throughput problems inside their ED, but no one's really taking the steps of using a telehealth visit as a triage in terms of getting the patients seen quickly rather than having them wait. I think that's one area you can really address throughput, even in the clinic space as well.

David Chou:
So these are things I'm thinking about in terms of how do we tweak the business model to utilize some of these solutions. And then when we start talking about telehealth outside the hospital, it gets a little harder because now as an organization, you're starting to support technology at the patient's home. And that becomes an environment that, that's more of unknown, but not necessarily impossible to task as just a different challenge that we need to think about in terms of exploring the solutions.

Dr. Carlos Urrea:
So David, thinking about that telehealth outside of the hospital or at home, or maybe alternative levels of care, you brought up a good point. We saw great utilization during the pandemic for, I guess what appears now to be obvious reasons, but now we're seeing a backward trend for that outside of the hospital telehealth. What do you think is driving that trend and reverting that momentum that the pandemic brought forward?

David Chou:
Well, I hate to say, I think last week, or maybe a week and a half ago, the rules just came out in terms of reimbursement models for virtual care. So when the money does not follow, these organizations have to figure out how to survive. So I think that's definitely a factor. The other factor is people still want to practice medicine face-to-face, and talk to the practitioners, the providers. They went to medical school, learning how to practice medicine face-to-face, so still reverting back to the old ways of practicing medicine, unfortunately. But I think the combination of the two is really a trend that we're starting to see. I think some of the prominent ones that are really forward thinking there still moving forward, like UNC with telehealth and virtual care first, but I think not everyone has that luxury and the capacity to keep at it if the reimbursement model and the revenue doesn't follow.

Dr. Carlos Urrea:
Got it. Joel, what's your experience? What's your health system seen and experiencing in terms of telehealth outside of the hospital?

Joel Ray:
So we did a major launch here of advanced care at home where we're essentially having our patients admitted to the hospital and it's at home, and it has gone very smoothly in terms of setting up the operation and the activity of care at the home. But that challenge is that reimbursement is not following. So I think that's one of the things that we and other institutions around the country are going to struggle with is how long can you keep making this investment unless the revenue becomes associated with it?

Joel Ray:
But I've been very pleased that the adaptation, our physicians have, I think, readily accepted advanced care at home. We do admissions both from our ED trying to avoid admission into the hospital. And then we also are looking from the inpatient perspective of where do we have the opportunity to cut off a few days in terms of being in the bricks and mortar facility and caring for those patients at home. It is very well received by our patients. They love it because they're in their own bed, their chair, their family members are with them. So that reception of it has just been fantastic, but that reimbursement, as David said, has got to come along at some point.

Dr. Carlos Urrea:
Perfect. No, that's always going to be a challenge. Let's maybe go back to the theme of burnout. Can we get some specific examples of what do you think are either technical or detail infrastructure that is getting on the way and is becoming part of the problematic aspect of the burnout? And then I'm weaving this question because I'm getting some questions from the audience that I think is going to help us enhance this conversation. So maybe Joel, I'll go with you first, some examples of where you think there are obvious problems.

Joel Ray:
Well I think it's interesting that David mentioned supply chain, but we're having supply chain issues all across the country in terms of products that are just not available anymore. And for that clinical nurse at the bedside, it means that the catheter that you used to use looked like this and the one that we can get today looks like this. And so you have to learn how to adjust and change your practice in order to be sure that we can care for our patients.

Joel Ray:
If you think about contrast mediums, there was a national shortage that we just have worked through in the last few weeks. And now, I think it's in different types of lidocaine and anesthetics that we're dealing with. And all of those things mean a significant change in day-to-day clinical practice for our care teams. And they're doing that on top of already working lean and dealing with these other frustrations and challenges that we were speaking of. So I think those are some of the key things that are really escalating the stress in the organization that we're experiencing today.

Dr. Carlos Urrea:
David, your perspective on some of the examples?

David Chou:
Well just based upon what I've seen, having standards is going to be crucial. I think clinicians do not work well when they have to deviate from a standard because they are dealing with patients' lives. So not having standard supplies that they could work with regularly, it really can cause harm. And I think that stress level is something they're always thinking about. Especially recently with some of the cases we've seen nationally about a clinician getting sentenced because of an accident. Right or wrong, there's a lot behind that. But I think that those [inaudible 00:34:14] and not having a standard really drives that even to different levels.

David Chou:
So I think technology doesn't help either. Look at the number of technology that we deploy at every organization. If I had to guess, UNC colleagues got hundreds of apps, all the organizations that I have been at that health system, so I have hundreds of apps. So how many of those are really used by all the clinicians? Tons. So the number of apps doesn't help, growth in technology doesn't help, not having standard doesn't help. So we got to figure out how to make it a lot easier. And that's what I really try to think about leading the technology. I don't have a magical, easy button to push, but these are all things I think about in terms of what can we do just to be able to drive a better patient outcome than how do we practice safer medicine.

Dr. Carlos Urrea:
So as we think about innovation and our audience is mainly innovators, one of the questions that comes up is AI. Of course, artificial intelligence. Do you have any strategies Allison is asking, do you have any strategies that you think with AI will support your health system and your clinical staff? David, why don't you go first?

David Chou:
Sure. So when I think about AI, just to level said once thinking, I'm sure everyone on this call knows that AI just an algorithm. There's nothing magical about AI. I think it's going to come down to whose algorithms do you believe in? Do you believe in UNC's algorithm versus a Cleveland Clinic algorithm? Because everyone's going to have their own version of AI, so we got to get to the point to where we have a trusted algorithm and we got to have these trusted insights being generated by AI.

David Chou:
So there's no magical solution behind this, but it's really important to understand that. And it's really important to also let the providers know, the nurses and the physicians know that, "Hey, this is what's getting created based on this AI. Do you believe it as a practitioner? Because the day you stop believing it, that tool's not as useful."

David Chou:
So that's my take on AI. We have made a lot of progress on the imaging side where AI can read images a lot faster and so forth, but I think we're still a little bit further away from being able to use that for other areas of specialty medicine. AI is one of those things where you got to have massive amount of data, so that's requirement number one. And number two, you got to have time. You got to have time to process the algorithm over and over to relearn and be able to fine tune it. So we will need some more time to be able to utilize AI in other specialty areas. But I am extremely optimistic that we will get there, but it takes some of the behavior tweaking that I also mentioned earlier in terms of practicing medicine to really take advantage of AI and not pushing back some of the algorithms that's being created.

Dr. Carlos Urrea:
Joel, anything that you can share on AI and the view of the clinicians?

Joel Ray:
Well, I think the other place where I see potential opportunity is especially in hospitals like ours that are nearly at 100% capacity each day. The development of AI algorithms to help our physicians see where we need to work next in terms of creating the greatest capacity, is it getting these group of patients admitted? Is it getting this group discharged? Because everybody's got their head buried in terms of their own work and the patients in front of them. But as we began to think about the throughput of an entire organization, I think there's some opportunity there where we can partner and help us to make the most out of the bed capacity that we have.

Dr. Carlos Urrea:
Thank you, Joel. I'm going to follow up with an interesting question from Valentina. She's asking about robotics adoption, but in the context of patient manipulation. Now she's asking the question in the context of workplace injury, but maybe if I broaden the question, borrow from Valentina, what do we think it's the future of robotics and coming to the bedside? Is that something that we think we will see? Joel?

Joel Ray:
Yeah, I think we'll see it. I think one of the things is going to be concerned is the expense around it especially early on, that is we're all limited by payer constraints, and so how are we going to be able to deliver on a technology like robotics at the bedside that will be affordable for us? I've seen we certainly have a lot of robotics in the surgical suite, but we don't have a lot of robotics outside of the surgical suite in our organization. So it does tell me that if it works there, it can work in other locations, but we've got some work to do to figure that out.

Dr. Carlos Urrea:
Perfect. David, what have you experienced with robotics so far?

David Chou:
We've seen robotics in terms of medication delivery. From that perspective, I have not. I think when we think about from a workplace injury, probably I have not seen that interesting concept, but I also think about the liability. What happens if that robot makes a mistake and hits the patient accidentally? There's some things to think about there. And then anything with new technology, there's always, I hate to talk about security risk, but how safe is some of these robotics that's going to be touching the network again? So now we have more and more stuff that's getting online. So not [inaudible 00:39:44] but those are some things that would definitely want to resolve early on before it takes off.

Dr. Carlos Urrea:
Perfect. All right. I'm going to maybe ask a question about the future. Let's go back to our 2040 theme and really getting a sense as to what the future will look like, and what's here to stay and what do we think? Now, nobody has a crystal ball, but our best educated guess. Now, I'm going to lump a few questions. We have for example, James Kelly is asking about hospital at home. Somebody's asking about non-clinical social media, additional unlicensed personnel. What do you think? We've seen some of these things already happening. What's here to stay? What's going to go? What's going to come new?David, I'll start with you.

David Chou:
Well, I'll call it the healthcare delivery at the doorstep, hospital at home, clinic at home. I think that's definitely a trend that will be here to stay. We're kind of going back to historical ways where remember concierge care, where people making house calls, the house visits? This is another version of that, 2.0. So it is definitely something that people are thinking about because as a patient/consumer, we do want to have care at a convenient location. But the one thing that people have not really thought about is the operations side of it, the logistics of it. So yes, we could do all the virtual care. You could do remote patient monitoring, but if you're really trying to do hospital at home, how are you going to shift the patient to hospital bed? How are you going to send the supply chain over for medication and some of the medical supplies?

David Chou:
So that's not part of the current operating model, so you probably need to figure out how to tweak that. Can you get it there the same day, just like Prime? Can you get there within the hour? I don't know. But these are the difficulty parts that no one thinks about and I think a lot of organizations are struggling with, but definitely hospital at home, I would say is definitely here to stay in terms of how do we provide care at a different setting while we're trying to shrink the number of patients inside an actual hospital room.

Joel Ray:
Carlos, I'd just add to David's comment that we're definitely dealing with that in terms of, we've had to define a 35-mile radius in which we can even begin to offer hospital at home. So as you think about it, there's so many criteria that they have to meet because it's a limited number of DRGs, it's a limited number of miles, it's a limited number of payers that we can consider for this type of care. So we've certainly got a lot of work to do in terms of expanding that in order to have it stick longterm and be a really viable solution for a significant amount of healthcare.

Joel Ray:
Then the other thing I would say is I do think we are probably going to see in the future, different roles coming forward, that maybe are unlicensed, uncertified, augmenting certain elements of care for which it doesn't really require that level of expertise. We are not great at defining that a lot of times because we have placed those tasks within the scope of certified and licensed folks. But I think if the shortage continues and it's worsening as projected out through 2030, we're going to have to rethink some of those models of care. Almost when I came into nursing almost 40 years ago, we really practiced much more in a team format, partnering with different levels of care team members in order to provide the very best in inpatient care. I can see a little bit of that is maybe not exactly the same, but revisiting it somewhat and allowing us to expand our capabilities with the resources that we have.

Dr. Carlos Urrea:
I'm going to borrow from Zach. He asked an interesting question about the future. David, you talk about organizations developing their own algorithms, but he's proposing, will there be room for learning health system networks that are either regional or by specialty? What do you think will be the level of willingness to share, infrastructure availability to have bigger macro multi sites, even though they're not from the same organization to really help develop that super macro level algorithm? Do you see a future where healthcare systems will be willing to share at that level?

David Chou:
Some. I'll say more of the academics may be more willing to, but as you're starting to see these mergers and acquisition across different states. You have Atrium, that's looking at Illinois, Chicago. Well, talk to UNC. Would they share some of the stuff they're doing? Maybe, maybe not. I think it's going to get very, very competitive. But I would say there's a lot of collaboration that will happen, but I just don't think people are going to open the books completely if there's a competitive advantage in terms of their AI or some of their solutions. I would say some of the big techs, the Microsofts, the Amazons, the Googles, they're all trying to play in the same space, and they're all trying to figure out how can they create a better tool platform. So I see those as great opportunities, but I just don't see lots of competing healthcare organizations that are going to have the same dollars in the same region, open their mind and say, "We're going to share everything." It may happen if they're not competing with each other.

Dr. Carlos Urrea:
Great. Thank you. Now I'm going to ask a question that I know is near and dear to our audience, which is the concept of co-creation and partnering with healthcare organizations and providers such as yourself. So when we think about this co-creation, like engaging with the startups or big medical device organizations, where do you stand in that willingness and ability to co-create the future and develop applications and technology? Maybe Joel, if you can share your experience.

Joel Ray:
So I do think it's important that we open up this dialogue between frontline caregivers and industry, so that we have the opportunity from the technology side to really create solutions to the challenges that our frontline caregivers are experiencing. Without that, you can end up creating a solution in search of a problem and that isn't helpful to anyone. So I think finding forums like this and others to open the dialogue and to really help our friends in industry to understand the very practical aspects of the challenges that we face in delivering inpatient or care at home, I think there is a great opportunity there to create the future.

Dr. Carlos Urrea:
David?

David Chou:
I would say that co-creation is definitely real for healthcare organizations, especially on the providers and the ambulatory space. As much as anyone would not admit it, most of the health systems IT department, they're not a development shop. We buy commercial off-the-shelf products. So the only way we could do things is really well innovatively is we really partner and co-create, so that's number one. But there's a gap that I see a lot where we have early stage companies with these grand solutions or things that they think work, but it doesn't fit into the operations. So I would definitely challenge early stage companies to figure out how do you get more embedded with the operating model for a healthcare entity? Because number one, every healthcare entity has some sort of nuance. Everyone thinks they're a little bit unique and special. So you need to understand that really deep to figure out how your product works.

David Chou:
And on the flip side, being a decision maker that buys technology, I would say we also have to figure out how to help and open up a lot more and not think of our ourselves as a development shop because we're not. So I would say those two need to really marry together, but I really challenge a lot of the early stage company who want to co-create to really understand healthcare operations very deep, not just superficially because those nuances are what makes or break a further discussion in terms of a co-creation or partnership deal.

Dr. Carlos Urrea:
David, that's a great, great insight for our audience. I'm sure many of them are really taking that input to heart. Can you think of a solution or maybe something that is ripe for disruption right now? Is there something that is under your scheme that you want to get addressed in the next couple of years or five years?

David Chou:
I would say it doesn't even have to be that long, far away. It could just be something simple. Just think about your clinic experience, going to clinic. What is your check in process like right now? Is it a very manual process or can you have a check in process similar to when you go to gym? For example, when I go to gym, I check in, I open up the app and I just scan my QR code and then I'm checked in. Is your healthcare experience as simple as that? Maybe. Maybe not. If not, can your solution do something that can solve that simple problem?

David Chou:
I think most of the time we try to create something that's extremely sexy, extremely longterm, but some of these simple pain points, they may go pretty far if you could just help us get there. There's lots of solutions that could do that, but can you integrate that solution into your hospital check in or healthcare clinical check in easily? If yes, maybe you have a shot. If no, back to the drawing board. So I would say that's how I think about the space in terms of creating innovation. It doesn't always have to be something that's complicated.

Dr. Carlos Urrea:
Thanks, David. That's very insightful. Joel, anything from your perspective that is ripe for disruption that you think it's ready to go away or that should go away and you need help with?

Joel Ray:
Well I think one of the challenges that we deal with on the nursing side every day is getting that medication history in from our patients that is accurate and current. And to come up with some sort of technology where that patient's prescription could be scanned and barcoded and entered into the health record and it reflect what is in that pharmacy database, so that we know that it's current and up to date, we spend lots of hours in terms of calling back different pharmacists, and a lot of patients are not great historians, and so really getting to that source of truth is very challenging. But all of that is documented somewhere and we should be able to access it and get it into the health record. So that's one of the things that one of our frontline nurses shared not too long ago is it would be so great if technology could help us with that. I thought it was interesting.

Dr. Carlos Urrea:
Perfect. Joel, as you interact with these startups and innovators, whether it's a big company or a small company what sort of questions do you expect an answer from? How do you approach these innovation that is brought to you and can you provide some guidance to the audience around that?

Joel Ray:
Well, one of the things that we have done in terms of approaching innovations brought to us here at REX is we actually bring in a team of healthcare of our own teammates, whether it's surgeons or nurses, and we expose them to the idea in the product, and we have a discussion about whether this is useful or not useful. Yes, it answers 70% of the issue, but there's this other piece that we need. And it's really sitting down and having that kind of dialogue with frontline caregivers, with industry that I think helps us to create and move faster to build better solutions.

Dr. Carlos Urrea:
Perfect. David, I think you alluded to that a little bit earlier around you want to make sure there is alignment with your process, but what are the questions? What is that interaction that you expect out of those innovation or innovative companies that come to you?

David Chou:
I would say probably show me something different that I have not seen before. It's a really crowded space. Every point solution is very crowded, so I'm looking for something that's very, very different. If I were to just tell you the number of emails I get by pitch or a new product, it's overwhelming. I probably only have 45 seconds to 90 seconds to spend on each one of these new emails that I make glance at. So it's important for early stage company, if you're trying to get some point across, figure out how to do something different and tell me something that I don't know. It's going to be crucial. So that's how I really think about, just because every space is extremely crowded and it's hard to be a differentiator.

Dr. Carlos Urrea:
Perfect. Well then I think you have time for the last question before I give the floor back to Steve and maybe talk about the future and talk about the challenges. One that we talked about came up a couple of times is reimbursement. We talk about whether it's for telemedicine, robotics or AI, whatever solutions. What do we need to do? Money is not infinite, so what are your thoughts about how do we address this challenge of reimbursement and paying for good care, paying for new technology and what should be thinking of in the next 20 years? And maybe David?

Dr. Carlos Urrea:
Hello?

Dr. Carlos Urrea:
Joel, are you there?

Joel Ray:
Yeah. I'm not sure if we lost him. I think that's a tough one, Carlos. I think we're all going to have to, as in the model David showed, we are all going to have to be much more agile in terms of pivoting quickly to build solutions. But on the reimbursement side, that isn't my area of expertise in terms of how we are going to get those policymakers and insurers to adjust to the changing dynamics that we're experiencing, because I really think one of the things that we're seeing with the increased chronicity of patients is that volume of patients that brings very little revenue is an increasing part of the volume of patients that we have in our hospital. And so much of the revenue-generating care is being shifted away from the inpatient setting to the ambulatory setting in other settings, and that further diminishes our revenue opportunity. So I think those are some of the things that we're definitely going to have to work through in terms of being able to finance inpatient care for those who need it in the future.

Dr. Carlos Urrea:
Thank you, Joel. I'm not able to tell whether David is back.

David Chou:
I'm back now.

Joel Ray:
I can see him now. Yeah, I think-

Dr. Carlos Urrea:
Okay, perfect. David, thank you. I was asking, were you able to listen to my question about reimbursement and how can we support and what can we do for the next 20 years?

David Chou:
That's a tough one. I don't think there's an easy button for reimbursement. I think all the organizations, all the hospital associations are trying their best to be able to get this upfront for reimbursement, but we're fighting with other initiatives as well. So I don't know how to tackle that one, but it is definitely top of mind, because if you look at the healthcare GDP in the US, we're the highest in the world, but at the same time, our quality's not there. So trying to figure that out with quality, I think it's an ongoing problem. I don't know whether we will even solve that in the next 20 years. Sad to say, but...

Dr. Carlos Urrea:
Yeah, it's a difficult one. All right. Well, thank you, David. Thank you, Joel. I really want to thank you for this. This was a great conversation as usual. Steve, why don't you come live and wish is all goodbye?

Steven Collens:
Indeed. Thank you so much all of you for your insights for spending time with us. And thank you to everyone in the audience for joining us today. I hope you'll join us for some of our upcoming programs, includes a showcase of medical device startups this Wednesday, a showcase of age tech startups on July 19th, a conversation with Ovia co-founder, Paris Wallace on July 20th. You can find all of our events on our website matter.health. David, Joel, thank you so much. Carlos, as always, thank you for your support and for excellent job moderating. I hope that you all and everyone else in the audience enjoy the rest of your day.