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Ann Nachtigal (Host): Well, thanks for joining us today on the Sanford Health Innovations podcast. I'm Ann Nachtigal, and I'm joined here today by Dr. Allison Suttle, chief medical officer at Sanford Health. Dr. Suttle, thank you for joining me today.

Allison Suttle M.D. (Guest): Yeah, thanks for having me.

Host:    Our topic today is innovations in medicine, specifically we’re talking about telemedicine and changes in the way healthcare is delivered, a rapidly changing landscape. Before we dive in, a little bit about you. I'm really interested in how you got to this role as chief medical officer. I know that you were a practicing physician for years, an OBGYN. In 2014 you were named as chief medial officer at Sanford Health. Tell me about how you found your way to this important role.

Dr. Suttle:  Yeah. So I'm an OBGYN by training. I moved back to Sioux Falls where I grew up to start practice. One of my mentors was really involved in—or really knew a lot of the administrators and was kind of involved in a lot of what was happening beyond just the clinical practice within our office. So I kind of got the bug from him a little bit about the bigger picture of delivering healthcare as a whole health system. So I went and got my MBA and then I started in administration as chief medical information officer. I was one of the few physicians that enjoyed the EMR and saw what the potential was there. Yeah. My role of chief medical officer, I think, was a definition extension of that. A lot of what I saw the benefit of the electronic medical record was how it could help us to standardize, to deliver better quality, to be more safe as an organization, and that’s really what the chief medical officer role is all about.

Host:    Okay, great. Obviously one of the things that you get to do as chief medical officer is speak before people and share your knowledge. I know that you just returned from a conference in DC. U.S. News and World Report Healthcare of Tomorrow where you spoke about telehealth as a population health tool. Tell me a little bit about that. First of all, just the experience of being a panelist, and then we’ll talk a little bit more about those terms. Population health, telehealth.

Dr. Suttle:  Sure, sure. Yeah. You know I love being a panelist. I think it’s always interesting to learn what the other panelists are doing, what their role is at their organizations, and how their organizations see the healthcare issues. The issues are the same, but sometimes the tactics and the solutions could be different or variable depending on resources available, structure, etcetera. So I always enjoy being on those panels just to learn from others. I don’t mind being put on the spot with a question or two. So I think sometimes that’s kind of interesting to see what you'll come up with when you get questions from the audience. The whole couple days, really, we had some great speakers. So Dr. Verma spoke. We had Senator Tom Daschle gave a talk. We had some great stories from some individual patients kind of on that patient experience. So it’s really, really a great time.

Host:    Awesome. So let’s talk about that intersection between telehealth and population health. I think it means different things to different people when you talk to them. How do you define that?

Dr. Suttle:  Yeah. So telehealth, I would say, is something that we’ve been doing since the telephone was invented. Physicians talking to patients wherever they are providing advice because that’s ultimately what physicians do. We provide advice. So that’s nothing new. Now we’ve added video. Okay, so that’s like facetime. Now you can see the person you're talking to, not just talking to them. So I'm a little cynical when I talk about telemedicine, but I will tell you it solves our geography problem. That’s been wonderful for our patients. We’ve saved millions of hours of them travelling from a rural community to come to see a specialist in Sioux Falls or Fargo or in Bismarck. So that time saved is very significant. What was interesting is I was with—The other panelist was from New York City. They're doing telemedicine because it saves time to get across town. It takes the same amount as it would for someone to get from Winner to Sioux Falls.

Host:    Interesting. Sure.

Dr. Suttle:  So it’s the time element and connecting people at different parts of a city or a state to be able to connect to each other. So it’s that access issue and time issue that it takes care of. Population health, the other part of the question. Population health is asking a group of people that you are responsible for taking care of and segmenting those patients into their care needs. Some of those patients are high risk, some are very low risk, some are rising risk. So we don’t just say all diabetics are the same. They don’t get the same care, four visits every year. There are some diabetics that are really high risk, and I need to interact more with them. There are some diabetics that are really low risk. They know what to do. Their medication’s working well, and I don’t need to see them maybe four times a year. So population health is saying there’s this one bucket of money that we have for healthcare. We need to make sure that we do more for those who really need it, less for those who don’t, and hopefully everyone eventually starts getting healthier. So we’re taking care to keep people healthy rather than just whenever you're sick, we’ll take care of you. Whatever your diagnosis, we’ll do the same thing for everybody.

Host:    Sure. Big shift that way, thinking ahead. Preventative.

Dr. Suttle:  Yeah.

Host:    What are some of the biggest challenges you see managing kind of that broad patient population? As you mentioned, very different sections. When we look at a particular health issue, what are some of those big challenges with that?

Dr. Suttle:  I think some of the big challenges are going to be in those populations that we don’t need to do as much care for, getting them used to do less. So we’re going to be doing this work with telemedicine with OB visits. So something near and dear to my hear. We’re able to define those patients that are really low risk, and we’re able to you don’t need to come into the office every single time. It’s a convenience and an access issue for you to—because likely they have other kids at home—to get everyone ready to go, come into the office for a 15 minute visit when you're healthy. You're going to have a normal delivery. We know that everything’s very likely to go okay for you. So what we’re doing instead is we’re having very few visits actually in the office. Only really when you need to see the physician. You might need an exam; you might need an ultrasound. Then those other visits in between you get to spend some time talking to a nurse about how things are going, is there anything that you have questions or concerns about. So we actually might end up with a richer interaction with the patient, but have the physician have a little more time available for those patients that are higher risk.

Host:    You talked a little bit about that patient experience. I think that’s a huge part of it, isn’t is, where I think looking at positive outcomes of patients that come through hospital doors is if you’ve had a good experience, perhaps your outcome might be better.

Dr. Suttle:  Absolutely. I think the more we connect with our patients, the more likely they are to have better outcomes actually.

Host:    I also read something where let’s say obviously technology is big right now, right, and we’re using telehealth to do that. But not everybody likes that, right? They want that personal touch. Tell me about what Sanford has done in terms of reaching out to that population that really needs that kind of one on one connection.

Dr. Suttle:  Right. That goes back to the concept of segmenting populations. So we identified a group of patients that I would say are disengaged is the word I would use. They were not showing up for office visits. They would end up showing up in the ER a lot more frequently than others. They weren’t refilling their medications. They had a lot of medical problems, but they weren’t interacting with us in a way that was very helpful for them. So what we did is we actually did a design thinking project with them. We went into these patient’s homes, we brought patients together, and we asked them what mattered to them and why they were behaving the way they were. It boiled down to we had lost their trust and that they felt shame. What they really needed was an insider. They needed someone that could help them navigate the system. The system was too complicated, and they felt ashamed that they weren’t able to kind of do what they needed to take care of themselves.

So it’s called a health guide, and these people are helping them fill out their paperwork for affordable housing. They’ll actually ride the bus with them because they're afraid to ride the bus alone. They understand what the social needs of that patient are. They understand what the care plan needs are, and they're able to break it down into goals that they can achieve. These patients begin to trust us again and they feel less shame. They feel very proud of what they are able to accomplish in terms of getting themselves healthy again.

Host:    Yeah. That’s a fascinating study, and I think that’s great that we've been able to connect with them on that level. It really brings up that larger issue of health is more than just our medical state. It’s our emotional, mental, socioeconomic. Where we live, how we grew up, bringing all that into kind of how we treat people.

Dr. Suttle:  Absolutely. I was talking with one of the other participants at the conference and they’ve developed a tool that really asks patient’s what they want. So it’s a way for us to screen for not only those social needs, those social determinants, but also what's most important to you? What are you most afraid of losing? What scares you the most about this illness that you have? I think that’s, again, another way to really connect with patients. The more we can do that, the better the outcomes will be for them.

Host:    Yeah, absolutely. What about the policy front? What would you like to see the federal government do to improve adoption of telehealth and access for patients?

Dr. Suttle:  Yeah. I think policy always lags behind technology a little bit. You kind of need to wait and let the dust settle and figure out how is this technology going to be used. One of the biggest issues that we face because we’re in multiple states is the licensure issue. When you don’t have that reciprocity where you—The way it works today for telemedicine is I, as a physician, have to have a license to practice medicine in the state where you as a patient have your feet planted on the ground, wherever that is. We know we’re a very mobile society. So my patients might be in Florida or Arizona or on a trip to Canada. They call me because they want help. They need advice, maybe they need a medication refill. Well we can't do that with telemedicine without that state licensure that can really be universal. That’s going to be a tough one. We do have some of that, I think there’s maybe 12 states that have gotten together and said there's reciprocity, but we need more of that.

Host:    Absolutely. It seems like a pretty universal need. You talk a little bit about Sanford and our reach. I mean we represent a pretty broad geography and really reach across the country, multiple countries. Are there any especially interesting policy moves or partnerships that have really helped in this area of telemedicine and adoption and innovation?

Dr. Suttle:  I think for us we’ve had a partnership with TytoCare. TytoCare’s a company out Israel that has created a doctor bag basically so that you can do in-home visits with a full physical exam. So this kit attaches to your phone. You can do heart exam, lung exam, you can look inside the ear, but you don’t need a doctor there to do it or a nurse there to run the equipment. It’s very easy for a parent to do this for their child or for you to do your own physical exam. Then talk to the physician. The physician can hear everything they need as if you were in person. So that takes that video visit, that telemedicine visit to the next level. Before it was just a conversation where you were skyping or facetiming or whatever you want to call it with another person. There's only so much you can accomplish there. So I think this partnership is going to allow us to really provide a lot more chronic disease management, a higher level of urgent care help for sinus infections of pneumonia. You can listen to the lungs. Also for chronic disease management. You can imagine those patients with congestive heart failure that maybe feel like they're not doing so well. Well, maybe we don’t have to bring them in every time. We can listen to their lungs remotely and then adjust their Lasix medications.

Host:    It’s pretty fascinating, really.

Dr. Suttle:  Yeah, it is.

Host:    Isn’t it exciting to be in this field?

Dr. Suttle:  It’s very exciting. I can only imagine flu season like five years from now. Everyone has their own doctor bag at home. Maybe their own little in-home lab and they can test themselves for influenza, get the medication they need, and never have to leave the house.

Host:    I mean talk about improving the experience, right?

Dr. Suttle:  Yeah.

Host:    Right. We’re in wearables. I mean I have my watch on me right now that can tell me my heartbeat and all that cool stuff. Lastly, let’s talk a little bit about just from the viewpoint of patients and clinicians about kind of these apps for telemedicine. What are some of the kind of pros and cons that you're hearing from patients and clinicians in this area?

Dr. Suttle:  You know, I think one area that can be a con and that needs to be overcome but can be is you have to develop a trusting relationship with a patient. That can be hard to do over a video. You can't always know what is that physician doing? Are they busy with something else off to the side? So I think you want to know that the patient has your undivided attention, that you're listening, and that you care. That can be difficult to do over video. So I think some ways around that are maybe having in-person visit first, establishing that relationship, establishing the relationship with the care team that’s closer to the patient so that you can get over that initial development of a relationship.

Host:    Dr. Allison Suttle, very fascinating conversation today. We really appreciate you joining us today.

Dr. Suttle:  Thank you.