Chris Hoyd  0:07  

Welcome back to Product in Healthtech, a community for health tech product leaders by product leaders, I'm Chris Hoyd, principal at Vynyl. Today we talked with Dr. Caroline Yang, the Associate Medical Director at Mass General Brigham, and a practicing physician in the Hospital at Home program. Dr. Yang shares valuable insights on the evolution of home based acute care, critical role of technology and enabling hospital level care outside of traditional settings. And we also touch on the exciting potential for AI and data analytics to transform patient care and the scalability of programs like that. Let's jump into that conversation.

Chris Hoyd  0:44  

Dr Yang, thanks so much for joining us today. Let's jump right in. So can you tell us a little bit about your journey into the healthcare at home space, and what sparked your interest in bringing acute hospital care into the home setting?

Dr. Caroline Yang  0:57  

Yeah, so I have always had an interest in the intersection of innovation, business and medicine, and really decided to pursue clinical medicine and do the full training and become a physician, because I felt like to really understand the problems of the healthcare system, you really need to live it day to day. And so that was really my motivation and inspiration to pursue clinical medicine, but always have an eye towards how can I innovate? How can I solve problems creatively, and how can I leverage, you know, nowadays, a lot of the technology solutions we have are great options to be able to address some of these problems that historically, we haven't had the technology advanced enough to solve.

Chris Hoyd  1:42  

Can you maybe talk about, you know, some of those most recent sort of technological paradigm shifts, and what you're seeing in your work today, as far as what they're enabling?

Dr. Caroline Yang  1:55  

Yeah, so I think, separate from medicine, technology has advanced tremendously over the years, and I think right now, it's that perfect inflection point of an openness to embracing technology within healthcare. I think with the pandemic, some of the silver lining was that we were forced into a situation that we needed to find a creative solution quickly, and we had the technology. And so it was really the change management piece that was really challenging to move people to a mindset that was more open and, you know, willing to try integrating technology more into clinical care. And so I do think that that shift has really allowed for many other doors to open where creative technological solutions can provide assistance or further solutions to a lot of our healthcare problems.

Chris Hoyd  2:53  

Very cool. Are you able to speak about any specific projects or, like, recent maybe launches or releases that you've been a part of?

Dr. Caroline Yang  3:01  

Yeah, so in the whole hospital space, we rely on technology greatly, and technology is really the backbone of allowing us to provide the care outside of the four walls of the hospital, because we need an ability to monitor these patients remotely and at all times and reliably. And so the technology piece is super important. And to be more specific, a lot of the remote patient monitoring that we do, we recently made a transition from one vendor to another in February, and that shift really introduced the opportunity to both standardize across our program. So our singular home hospital program across five sites has really allowed us to scale our program and to care for more patients, because we have the technology and the capability to do so safely. And it's always a work in progress. I think other digital solutions, obviously, we work heavily out of the EMR and so at MGB, we use epic, but we really have had to cater and build special solutions for the home hospital space because it is so new, and adapt some of what exists within both the inpatient space and across the ambulatory space, different functionalities that have you know together allowed us To deliver home hospital care through Epic in really meaningful ways. So I think those are probably two big examples of technology and how important it is for those technological solutions to be of a reliability and an accuracy that will allow us to care for so many patients at home at one time.

Chris Hoyd  4:44  

Interesting. So I'm curious about that sort of constellation of stakeholders and products and how they have to be connected, integrated, interoperable, and where you and your team sort of fits into that. So obviously, Epic is the, you know, 800 pound gorilla. In the, in the, you know, health system space. It sounds like you've just started working with a new vendor focused on remote patient monitoring. I'm curious just, you know, and not to get too in the weeds, but what does your team look like, sort of sitting in between them, discovering new integrations or new features or even new products to sort of innovate or build. How does that sort of factor into your your day to day, and how's your team do that?

Dr. Caroline Yang  5:28  

It's definitely an ecosystem, and there's definitely many players. I think the key is really the communication piece. So for example, when we were moving from our last vendor to our current vendor, a lot of the build part and before go live, was focused on, how do we get the information that is most important for our clinicians to provide the best clinical care they can, and how can we leverage their technology in ways that are meaningful to the way that we deliver care, our existing workflows, and what adaptations do we need to make based on the technology that they have? So it's completely bi directional and dynamic, and we are still every day, iterating, improving, giving feedback from both ends, and that is absolutely imperative to having this be successful, and to have that collaboration between industry and also the healthcare provider and in a way that really supports the provider and the clinician, rather than hinders them. Because we all know, you know the history of EMRs from the very beginning, I think oftentimes the clinical input has been less front of mind, and a consequence of that is that because these people are the end users, there ends up being a lot of friction and barriers in utilizing the technology. So I think that those lessons learned definitely informed our approach to taking on this new vendor and building escalation protocols that are relevant to us and fit our workflows, and also creates the least cumbersome on ramp or learning curve for our existing team members to adopt this new technology. So the change management piece is huge and probably one of the biggest barriers. So I do think that communication and the dynamic nature of the relationship really informs a lot of the enhancements and progress we make together to be able to provide the best care that we can to our patients.

Chris Hoyd  7:40  

So now I'm kind of curious about on the patient side or the outcome side. How are you measuring success, like, what are some maybe success stories you've seen recently? How's that going? And where do you sort of, you know, see things advancing in the near future?

Dr. Caroline Yang  7:56  

So anecdotally, absolutely, have heard many, many stories of patients that I myself have directly cared for, that you have family members and you have patients really expressing gratitude for allowing them the means to stay at home and be cared for at home. Because this is, I mean, we talk full circle of back in the day when we did home visits with your primary care doctor. But this is actually, you know, a step higher or a new world in that we're providing acute level care, inpatient level care, to patients in their home and leveraging the supports that they do have in their existing home environment to make it the best experience it can be and the safest experience it can be. And so we oftentimes will have people who end up back in the emergency room for maybe something else in the future, and they're always asking, can we come back even before we've really screened them to say, yep, you're appropriate. So that's definitely a testament to people who have had a good experience and had that satisfaction, and even more so now that we're at a scale that we are we're hearing, oh, my mother did that program, or my friend did that program, or, you know, my cousin did that program. So there's just the word of mouth has been tremendous to share with us that it has provided a lot of benefits and patient satisfaction to our patients. So that's definitely a testament. And I think in terms of, like, how we measure success, I think that's a huge part of it is the patient experience. Like you cannot neglect how important that part is in continuing to scale, continuing to grow, and finding the motivation internally with your team to say, this is meaningful work, and we're finding meaning as providers in doing this type of work in the home. And of course, we have standard metrics like, you know, readmission, 30 day readmission and length of stay as a barometer to see how we're doing relative to prior. But I do think there's just not enough that can be said about the true on the grounds patient and provider experience of this hospital at home program.

Chris Hoyd  10:03  

Yeah, that's incredible. Okay, so I'm curious now, if you can speak a little bit at least to the details of the kind of the tech that is used in the patient's home, and I'm sure there's some variance, but when you think of maybe a typical patient setup, what kinds of like, what's the interface, what kinds of equipment might be in the home.

Dr. Caroline Yang  10:27  

It's interesting, this has evolved a lot. So I started in 2020 with home hospital program as a provider. And back then, you know, we had, you know, three to five patients on service a day, and it was really just one MD on a day, and it was one to two nurses on a day for the entirety of the week. And now we've scaled to, you know, we have a bed capacity of 50 right now, with an average daily census approaching 40. And we have many paramedics and nurses and APPs and MDs who are all part of the team, including many other non clinical members that support our everyday and talking about the technology when I started, was really patchwork. We didn't have an RPM platform, per se. We had individual device solutions that provided data that maybe had their own app or web platform for providers to adjust thresholds and look at data. But it was really kind of put together in a piecemeal way. And then, you know, I supported the onboarding of all of our team into Biofourmis, which was the vendor that we used prior, and in this was in 2021, or so. And that shift really put us onto a platform that was more cohesive. We weren't in so many different interfaces, and it allowed us at least a step closer towards, sort of the integration and sort of having a one stop shop and their device. I mean, the devices were all most of the ones that we use regularly were connected. We had a vital patch that did sort of the continuous ECG monitoring and some of the other continuous biomarkers. And then we had the blood pressure cuffs that were Bluetooth enabled and scales that were Bluetooth enabled. And I think with time, the user experience changed and that we were actually engaging more of that connectivity, in that we were actually connecting our scales via Bluetooth and all that. And now I think we've evolved to a place where, in the most recent transition from Biofourmis to current health, which is our current vendor, you know, I think with every change, you lose some things, you gain some things, you learn some things. And so our current setup is, we have, you know, a single lead continuous ECG monitor and a false detection solution that is kind of run separately or is not integrated. And then we have our RPM platform through current health that does a lot of the other continuous monitoring through their own proprietary armband that does some continuous monitoring with temperature, pulse, oxygenation. And then we also have Bluetooth enabled Oximeters and scales and blood pressure cuffs that kind of come with that. So largely the same build, but obviously just a little bit of difference in terms of, like, who owns what piece. And the goal is with current health and these other vendors, the falls and the ECG, that they'll all be in the short road ahead, integrated into the one platform. So I think we're constantly improving, constantly getting feedback. And I think again, it's really important to take the feedback of the patient experience and the provider experience to inform where we go next, what capabilities we need and what we ask for.

Chris Hoyd  13:46  

It sounds like a fair amount of that data you might be getting, what you're tracking, enables you, you know, to react quickly to to something, whatever harmful happening to a patient. Is there when you think of like the Holy Grail, as far as like functionality for this kind of thing. Does it get into, you know, anticipatory interventions or preventive like, what do you sort of imagine out in the future that we would love to see?

Dr. Caroline Yang  14:09  

I'm a big proponent of how much we can integrate AI into clinical medicine, and I do know it'll take time, just again physicians and other providers and other clinicians that we're so used to doing some things one way, and it provides this, this sense of security and safety, because that's paramount when you're taking care of patients and so but I do think that AI solutions can really work to augment the function of our on the grounds providers and are, you know, warm human beings that are, you know, here to provide the care, because our bandwidth is only so much, and so having the support of technology to be able to do predictive analytics or to do anticipatory  guidance, or to help triage patients based on sort of preset algorithms, I think is is going to be super important to be able to allow us to scale the way we want to, and to avoid clinician burnout, because we can only do so much. And so if we are feeling really supported in a lot of the more manual tasks, or a lot of the other tasks that can be automated, that leaves us way more bandwidth to actually be with the patient, to be bedside, to think more about the complex cases that we have. And so that's really where I see us moving towards. And we need to leverage a lot of the smart technology we have to be able to get there and to scale to the degree that we want to. Because imagine, like, if we're monitoring, you know, 200 patients at one time, it's really nearly impossible to catch everything and to and if you see, even if you see it in front of a computer for the entire day, non stop - human error allows you to miss things, and it compounds, because people are exhausted, like they'll miss things. And so having that technology, like I said, to support and augment the function of the people that we do have is going to be super important, and in many, many ways. So I do think that the also just personalization of care, using technology to say, like, you know, based on this patient's story compared to other patients, of their demographic or of their comorbidities or their experience in home hospital, we can predict that their length of stay will be this or we can predict that they might have this complication, or we might predict that they will probably be escalated back to the hospital based on everybody else that's preceded them. I don't know that it's a good idea to take them, or if you take them, Let's mobilize resources early so that we can try to prevent and minimize the chance of them decompensating. So I think there's a lot of opportunity that we haven't even tapped into yet, and will continue to grow and be more reliable as the technology advances. So I think this is really the time, and this is really the time for industry and healthcare providers to come together at the same table and say, hey, we were trying to address the same problem, and there will need to be openness on both ends. But I think in medicine, the key really is like, how does it impact the patient experience and patient outcomes? How does it impact providers experience, and then, how does it eventually, you know, for better, for worse, support the bottom line of hospitals to stay afloat and to find that return on investment that they need to see to be able to continue to scale. To put investment into these programs, to allow them to grow, and I think we're just right at that point of shifting into something that could really explode. And so I think we're well on our way, but I do think that sort of next key is the technology, because that will allow us to move to a whole different level that we historically haven't been able to.

Chris Hoyd  18:05  

That's incredibly exciting to hear about. And that really beautiful vision, it sounds like it, it's not, you know, it's not science fiction anymore. I'm curious, sort of, from the product management or product leadership angle, that is an ambitious vision, right? And there are stakeholders, each with their own roadmap and agenda. And, as you said, business model, if you could speak a little bit tactically, how do you and your team managingthe vendor, the EHR, how you want to scale, you know, while maintaining reliability and honoring the patient experience? How do you sort of synthesize and prioritize through that whole, you know, maze of data and feedback and agendas like, how do you how does your team do it?

Dr. Caroline Yang  18:52  

I would say first and foremost experience. The nice thing about, you know, MGB, home console program is we have a lot of history, and so we have learned a lot through trial by error, which I think is, realistically, the way that we move ahead in all of this is that it's new. So there's no way we have a like blueprint of what the right approach is or what's going to be the most successful. And so we're kind of living it and writing it as we go. And so I think that's the exciting part of it. There's obviously risk involved, and I can, from the provider standpoint, see where that risk feels a lot heavier, and often is because we're caring for patients and want to provide the best care. And if we don't have certainty that the technology side or the industry side has the best interest of the patients and the providers at heart, there really is no path forward, and so having that openness to that conversation, all being at the table together, like I said, with our vendors, it's always a back and forth conversation. It's not like we deploy and then we're done. We're constantly doing new improvements, new releases, new updates, and we're in constant conversation in weekly, bi weekly meetings with our vendors to be able to provide live feedback, get their feedback, and know what their capabilities are, know where they're advancing in their technology. Does it align with what we're looking for? And then building a roadmap together to be able to collaborate as we move forward. Because again, with historically technology business and like healthcare, oftentimes, have been very siloed, and so products are being created based on problems that people think are problems, but haven't really investigated further, or they're retrofitted. They build a solution, and they try to find a problem, and that's where you get a lot of wasted dollars, wasted time, and I think that right now, it's really just from the get go, having everybody at the table who is a stakeholder, understanding the difference in their motivations and in their bottom lines, and then moving from there and recognizing you're not always going to align, and where you need to make some compromise. You make the compromise that is appropriate, and that's a big part of how we decide, as a healthcare provider, who we engage as vendors. Because we really need to vet to say like, A, does this fit our workflows? B, is their their culture in their work culture aligned with ours? And C, like, do we see a future roadmap based on kind of their prior engagements or prior solutions or whatnot - Do we see a continued relationship forward, and can we fulfill a lot of our goals in our future with the support of their solutions? And so I think that those are all things that need to be strongly weighed and considered when looking at what vendor relationships are, ones that are worth pursuing. And so we do look at a lot of that, because there's so many devices, there's so many solutions, there's so many software solutions. So we really have to think through like, what makes one more favorable? Or, I guess you could say aligned is a better word than another. It's not that the product necessarily is better, or what they're offering is better. It's just that it aligns better with what we're where we are now.

Chris Hoyd  22:14  

I think that's some incredible sort of wisdom that you just shared with, you know, possible health system buyers of this kind of a product, I think, yeah, it sounds like it has very little to do with what the sort of latest, you know, sexy wearable might be, and much more to do with the culture around collaboration and communication and advancing that shared vision together. How would you sort of assess your your program in the in the broader, you know, scheme of national health systems that are exploring hospital at home capabilities like it sounds like you guys have are sort of on the forefront of it. You've maybe scaled more than most. You have deep integrations in the the broader organization, including the business side, all these things I can imagine other health systems maybe struggling with a little bit.

Dr. Caroline Yang  23:06  

You know, seeing that journey has been really informative and also puts us in a place where we have a lot of insights and learnings to share. Because why should another program that just starting have to struggle through the same many years of challenge and and, you know, mistakes that we've already made and can share with them. So I think that's a big movement in terms of home hospital as a whole, is that there are more programs now. There are more people having these experiences that can share these experiences, more people innovating in the space and having creative solutions or engagements that we can learn from. And so that is kind of what I have found to be such a blessing is that even though we have the experience, the years of experience we have - now that we have so many other brains to tap into that are in this space, we can grow and improve even faster than we otherwise could have. And we're also accumulating a lot of data and being the program that we are. I mean, I believe we're the biggest program currently in the United States, and if not the biggest, we are one of the biggest. And you know, our I can say for our metrics for last month, you know, like, our average daily census is about 40, and our capacity is 50. And in August, we are going from 50 to 70 patients capacity. And then we're also expanding in the mid month to 72 towns around the greater Boston area from 66 and so we're constantly growing. You know, we screen almost, I think last month we screened almost 10,000 patients, you know, for to see who's a good candidate for hospital. And our last completed month in June, we admitted like 236 patients. And so it's really great, now that we have all this data that we're collecting, we can actually do a lot of iterative work and reflect on, you know, how are we doing, and then really doing root cause analysis and looking into how can we. Find other creative solutions to address some of these challenges that we may be seeing evident in a lot of the data that we have in our sort of analytics. So again, we would didn't have the volume to do this prior, and obviously the technological capability to do this prior, and so this is all internal. But imagine take that and take it across all programs. Like, there's a lot of data out there, and there's a lot to say, like, around safety and around what is like, what technologies people are using and learning from, you know, solution people are building within their EMRs to support their hospital home program, and then not just help providers in terms of, like, hospitals that have homegrown programs, but you have other industry players that are kind of have a plug-and-play model of home hospital, and are bringing their product and also can contribute a lot of knowledge. So it's just very exciting, I think, for me as a leader in the home hospital space, to be able to know that there are so many things that other people are doing well that we don't have to trial by error for we can learn from them, and there are a lot of great groups across the nation that are focused in hospital at home, and allow us to come together and, you know, define best practices and to discuss what we've learned. And so I think that's very exciting and something that wasn't possible when we didn't have that many programs to share knowledge with. And I imagine it will only continue to grow.

Chris Hoyd  26:23  

Since you are at that scale, I'm curious about the demographics who are the sort of primary recipients of this program, and how do you think about growing it? Is it growing within that demographic, or is it looking at other sort of target audiences or patient populations?

Dr. Caroline Yang  26:42  

Well, I would say the good news is that when we've looked at our demographics, we match pretty well to what's the traditional inpatient model. I will say there are some - I wouldn't say discrimination per se, but inherent exclusions that we have to put into place in order to have a successful home hospital admission that will select out for patients who are homeless, patients who have substance abuse, not so much by race, but if you talk about sort of the hidden factors of like, you know, socioeconomic status, therefore maybe predicting likelihood of having home supports or being homeless or having substitute problems, could be part of that mix, but in large, just across, like race, ethnicity, female, male, and then also age, I would say we definitely, it's pretty comparable to the inpatient but I think for age wise, we definitely have more geriatric population, which is, you know, I think really great, because it supports the sort of aging in place movement that's been going on for like a decade now, really trying to figure out, how do we support our elderly and their dignity and autonomy, which in big part, is allowed by being in the home and supported by the loved ones that they do have in the home. And I think this was actually funny enough, a blessing during the pandemic, when we had really limited visiting hours, and visitors were only allowed, like one person at a time, and you have people who are living in a home of full of loved ones and supports that now, if they're at home hospital during the pandemic, have the ability to be supported by their loved ones, and then I think that makes the transition from hospital back to their home home situation after discharge a lot smoother because they are already in the home. So we have been able to figure out, how do we leverage their home supports and like, even their home environment? Their home setup. The bathroom is here, their room is here. Like, can we get them some medical devices to help them, or, you know, durable medical equipment to be able to make their life easier? And we can see that, and we live it with them, and that is so unique to just being in the home. And so I think it really favors and supports the geriatric population. And I think in large the geriatric population tends to be the type of people who get admitted to the hospital. So again, I don't think we're in any unbalanced way selecting more for them, but I do think we support them in ways that are really unique and really, really valuable. And then, of course, we have our young folks who are super independent and don't really need to be in the hospital if they're getting IV antibiotics once a day, and don't need anything else really, and are super independent, and I think they benefit hugely from the program too. So I think, you know, to circle back to sort of the split. I think we want to be equitable to sort of what the inpatient setting is, as much as we can be, and then from there, whatever we can support - so we are going to look at homeless hospital at home. We are going to look at rehab at home. We are like, these are all things I can see in the future, if not already in motion, to provide for more people and to even take away some of those inherent barriers that we currently have. So I think that that's a lot of the work that we're going to do is build new clinical pathways and build new pathways that support certain social environments or social histories, and then, you know, I think a lot of the patient identification work that we're doing. Now can be even further sophisticated to be able to triage patients based on, you know, varying factors that allow them to be a good candidate or a less good candidate for our program.

Chris Hoyd  30:15  

Thank you, Dr Yang, so much. If anybody wants to find you online, how can they reach out to you?

Dr. Caroline Yang  30:21  

The easiest way to find me and reach out to me would definitely be through LinkedIn. Feel free anytime to connect, and if you have ideas or questions thinking about your own home hospital program trying to build up your home hospital program. Would love to hear and learn from your process. So definitely do not hesitate to reach out. I'm Caroline Yang, MD, on LinkedIn, and definitely reach out and look forward to hearing from some of you.

Chris Hoyd  30:49  

Thanks so much for joining us. You can also connect with us on LinkedIn, YouTube or on our website at productinhealthtech.com, if you have ideas or suggestions on what you'd like to hear in a future episode, or if you'd like to be a guest, please just shoot us an email at [email protected], thank you.