COVID-19 is a watershed moment for digital gastroenterology – Interview with Dr. Atreja, Chief Innovation Officer at Mount Sinai
I spoke to Dr. Ashish Atreja, the Chief Innovation Officer at Icahn School of Medicine at Mount Sinai. He’s a well-known keynote speaker in the field of digital medicine. Also, a board member of Rx.Health that released the Virtual Care Hub (with AGA) this week.
He called this a “watershed moment” for gastroenterology. This interview has so many insights that it deserves to be watched in full and a few times.
Watch this interview to get insights on:
◘ The situation on the ground at Mount Sinai in NYC
◘ How New Haven uses Rx.Health to track employee wellness
◘ 90% of work of telemedicine is pre-appointment
◘ We are laying the foundational layer for digital health
◘ How’s the GI department at Mount Sinai responding
◘ In a massive outreach to patients – 40% agreed to be monitored regularly
◘ What should a private practice do to move towards digital GI?
◘ Is healthcare now local or global+local?
◘ Can I become a global IBD doctor?
◘ Five years from now how will the GI world look like?
The Transcribed Interview:
Praveen Suthrum: Dr. Ashish Atreja, thank you so much for joining today and I welcome you. So, you are based in New York and New Jersey. How is the scene on the ground?
Dr. Ashish Atreja: It’s changing very fast Praveen. I think two weeks ago when I was in the hospital, it was chaos, I would say controlled chaos but still chaos. We didn’t know protocols; we didn’t know how much patients were going to come. 80% of our capacity was all COVID. This time when I went around last week, I think we know it’s bad, but we know how to manage it. We have increased our capacity significantly. So, it’s getting better since last week and that’s very heartening. I know the patterns are going to last long, there are going to be many more mortalities. But I think we have learnt how to manage majority of the patients. Which is very heartening.
Praveen Suthrum: You are the Chief Innovation Officer at a very large health system and a very busy hospital. What steps did you take as soon as you got wind of the crisis, how did your role change?
Dr. Ashish Atreja: Yeah. That’s a great question. I think one of the things we realized that the heart of everything is… how different streams came together. So, the marketing team, the communications team, the Chief Medical Officers and the medical operations, and the digital health team and the core IT team, everyone came together in a command center way. We have daily to twice daily huddles. To know around health system wide to see what’s happening and what’s not happening because things are changing so fast from equipments to supply chain to healthcare workers getting sick, there is lot of moving pieces. One of the things we started doing was… we already have a building capacity for digital health for the last six- seven years. I lead the digital innovation center called AppLab there so, we rapidly turned our capacity in partnerships with other groups as well at Sinai to have just a complete online presence. So, people can just have what we call as Mount Sinai Now which has been our initiative to telehealth for some time now so, anyone can come and get an immediate video visit. We have also turned on our ‘text to talk’ through one of our partnering groups where anyone can come on the website and chat with anyone and we actually enroll medical students and others to be able to do the light touches there. We have also turned on our behavioral assessment because there is lot of anxiety and stress that happens and also bereavement that happens.
We have also launched a public health very big research initiative called ‘Stop COVID NYC’. We reached out to 14,000 patients in the first day itself which is text to enroll and a chat bot now we have around 30,000 people already enrolling to that within a week. The goal is to reach 1 million+ patients in a very easy goal in the prescription manner, we are able to prescribe right on their phone and activate them into a research registry.
Praveen Suthrum: You also run a spin-off called Rx Health that came out from the Mount Sinai AppLab and you recently partnered with AGA to announce the Virtual Care Hub. How is this linked with what’s happening within Mount Sinai and is it more targeted at other hospitals, what is the difference?
Dr. Ashish Atreja: That’s correct. So, in Mount Sinai we are using the same platform internally and we’re learning what the needs are and Rx Health becomes I would say that glue which takes those needs outside to serve other health systems and other GI practices. It also works the other way Rx Health is also our sound bite as we speak or a sounding board to know what is needed in the community even if we don’t feel it from Sinai and things get built and we take it internally at Sinai and I can give you an example of that New Haven which has partnered with Rx Health actually had a really big need of tracking their employee wellness and workforce what happens to them every single day because most of them are distributed remotely so they helped with Rx Health to create a program for employee wellness and workforce management and we believe that is such a critical element that we can now plan to bring it to Sinai or plan to bring it to other health systems or GI practices as we are starting with that. So, it becomes a network of networks where there is one platform and we are able to see the needs and are able to rapidly able to ingest the digital assets for example in Virtual Care Hub we put the asset of telemedicine but not just telemedicine as a video visit because 90% of the work in telemedicine is pre-appointment, make sure the patient comes up, make sure the patient downloads the app, make sure they show up in the room, and the post-visit follow-up. So, it creates a whole continuous eco-system from appointments to follow-up but also monitoring and triage so about. And the goal is to not only serve the immediate need of converting in-patient appointment to virtual appointments but also rapidly build the foundational layer of capacity for digital health so when the recovery period happens, all the GI practices are actually very much at par with the infrastructure that is needed to provide a high quality care and combine digital with in-personnel seamlessly.
Praveen Suthrum: Coming back to Sinai. How is the GI department in the hospital or the different hospitals what’s happening there?
Dr. Ashish Atreja: Yeah. Oh, leadership under Bruce Sands and David Greenwald, rapidly structured all our services so, in fact instead of having regular so many physicians at Sinai, being in the hospital, we took turns to be in the hospital and since 80-90% of the patients were COVID, we actually partnered with a GI fellow but also are in the medicine service taking care of COVID patients. And as a small team dedicated itself to the GI service, GI councils and the leaders. So, I think the restructuring was very rapid and was very well-done and we refined it over time to meet the search capacity. Now, one of the things that we have learnt is that few patients are coming in with diarrhea, nausea and vomiting as presenting symptoms. So, the more we are aware of that we don’t have to immediately scope them we are able to actually watch out and do a COVID test and if it is COVID we watch for it or rule out CRP number. So, there is definitely overlap with GI symptoms we are starting to see more and more anti-coagulation now that we have to use in these patients. I’ll give an example – an average COVID patient has a CRP or inflammation of around 150 which is one of the worst that UC (Ulcerative Colitis) patient has before surgery. So, there is so much inflammation that leads to fatigue, but that inflammation also becomes prothrombotic to lead to blood clots and PE and we have already seen a lot of patients coming back with PE.
So, rapidly we have changed protocol for anti-coagulation, and they are going to be public soon, but the flip side of that is that can lead to some more bleedings in the hospital. So, we have to be very cognizant of that for the incoming patient population as well. The third part that we did for GI population is for IBD. A lot of patients with IBD were on immuno-suppression and they actually told us that they want to stop immuno-suppression because they don’t want to be affected by COVID severely. So, we had to do a mass-outrage. So, we were able to reach the same RxHealth platform and reach out to 5,700 patients engage with the, educate them and also gave them the probability if they want to be monitored on regular basis. So, 40% patients agreed to be regularly monitored. And out of those 40%, if you ping them, 80% actually follow-up and report their symptoms. So, we have just created a real-time registry of activating preventing patients and that’s actually a great model which can be scaled nation-wide not just for the IBD patients, but we can adapt the same strategy for our healthcare workforce as well which maybe at even bigger risk because of their exposure to COVID.
Praveen Suthrum: That’s an amazing statistic, right? So, clearly, we seem to be moving towards a digital phase. Not only GI but all of medicine. But I’m interested in your views in what does digital gastroenterology look like beyond the telemedicine stuff which is happening right now.
Dr. Ashish Atreja: I think this is one of the most fascinating parts from digital GI perspective. I think while the virtual health is obvious, I feel there are going to be three other streams that are going to be very pivotal and they are going to change… I think it is going to be a watershed moment for medicine as a whole with respect to digitization and gastroenterology specifically. Telehealth, virtual health, of course taken for granted and I think it’s more than just the video visit I think it’s about engaging the patients before and after. I would say real-time digital registries and trials are going to be the other part. We are actually planning to scale up to our next phase for our AGA initiative to setup a nationwide clinical trial network which is completely digital recruitment. So, you can do recruitment through e-consent bot which we are currently doing through Stop COVID NYC to ePRO which we have been doing for the last five years through NIH funded initiative to actually combine the data with EHR to do real-time digital registries and clinical trial enrollments. The third of course there has been lot of discussion and Praveen you have been in the thick of that is the AI part for endoscopy. And I have started seeing conversations of AI being used for lesion detection and others and then standalone companies doing actual partnerships or becoming part of the major GI endoscopies after this. That is when it becomes a double mixed role or what we call as translational otherwise it is just a standalone tool which people do not use.
I think these three things virtualization video visits, registries and clinical trials all virtual, clinical care research and AI augmentation part I think will also create new models of population health and better aligned GI which has been typically fee-for-service in many ways with ACO’s population and health plans for bundles for payors. So, I think we never had the capacity but now, we will have the capacity post COVID to be able to go to health plans and negotiate bundles because we are able to look at populations as a whole.
Praveen Suthrum: That’s very interesting. Now, it is one thing to talk about digital health as Mount Sinai and quite another thing to talk from a private practice perspective. What does the everyday practice on the ground do right now at this time, in this period in preparation of this whole digital phase of gastroenterology that might surface right after this pandemic settles down.
Dr. Ashish Atreja: One of the key things… this is actually in a way, even though it is a moment of crisis, it is a great moment for capacity building. The in-person appointments or the endoscopy volumes which was keeping all gastroenterologists, many of us, busy is lesser, lighter or not there. So, that frees up time to build operational capacity, digital capacity training and really optimization to make everything seamless. There is a concept in digital health which is, for technology to really be effective it has to become invisible, right? Like internet is invisible, but you still use it. But you don’t have to say how you are going to go to the internet. It just happens, right?
So, lot of our work at Mount Sinai with AppLab but also working with AGA as part of the Virtual Health which is national transformation and I would say it can be a great model for global transformation for GI through partnerships is to make all the knowledge we have and all the experience we have as an open network, open knowledge network to everyone else but also set up a steering group of people in IBD and others to come together to be a guiding force and also doing tutorials, learning lessons and sharing things through journals and through publications. So, use this time to absorb and assimilate, increase capacity and make our practices so super-efficient that technology is not a barrier technology really becomes a facilitator the way it was supposed to be but never got a chance to do before.
Praveen Suthrum: Right. I have one other question on this whole connection between digital health and healthcare being local. Forever now we have talked about how healthcare is very local and is very different from state to state from hospital to hospital and region to region, right? But if anything, that this crisis has shown that is healthcare is both local and global at the same time. Within a matter of weeks things spread to every part of the globe. So, again I want to connect the dots back to GI. How do you think in this whole phase of digital GI that we will get into, how is it going to affect the regionality of healthcare? That we are so used to right now.
Dr. Ashish Atreja: That’s a very good question. I think… you know this is going to be a watershed moment not only in technology but also in practice and research. The practice patterns are going to change, the referral patterns are going to change. You can imagine… I don’t know how long the government will stay this way… But you can practice across the border. This is the first time since I have been to the US in last 20 years that I can actually treat any patient across US in any state. That was possible in India before and I can still treat patients in India in any state, but I could never do that in the US but now I can. So, it is possible that it may not be taken away. So, suddenly… well you always can dream, right? I still haven’t stopped dreaming. Can I become a global IBD doctor, right? Because IBD care is so much centered around sub-specialized center that we see a lot of gap, lot of disparities in the geographical areas, in remote rural areas, even if you go 100 miles away. Can we completely break that barrier? And decrease the disparities, right? People becoming global physicians in that regard. And that was only a dream but I think I can see some segments of that dream actually may become real and there are many other doctors who may take that or healthcare professionals who may take that.
I think sometimes if you haven’t tested anything you don’t know how it is possible. So, there’s a concept called self-efficacy which means I want to do it, it is a good thing to do, but I don’t know how and that is stopping me from doing something there‘s lot of literature in smoking cessation to behavioral things. But I think physicians as a work force have this self-efficacy in fact all of us as humans do or lack of self-efficacy is when we say “hey I do not know how to do it, it’s too big and I’m too tired to do it right now”. This moment will increase your capacity and self-efficacy that many of us will continue to march ahead. I truly wish the GI community takes it. It’s not just one or two people, it is actually that majority of GI should take it and become a more national workforce than just hyper-local workforce knowing that some of the procedures will always remain hyper-local but the reach from an out-patient practice, from a consultative nature can become much more regional and eventually global.
Praveen Suthrum: That’s actually very interesting to hear. Thanks for sharing all these points. One final question. You are talking about dreams and you are a gastroenterologist and a technologist at the same time, a very rare combination. My question is, five years from now, and if you have to look ahead, how is the GI world going to look from your lens? If everything that you have imagined comes true.
Dr. Ashish Atreja: That’s a tougher thing and you know why Praveen. We have learnt that you can never predict what happens in technology five years from now. And Bill Gates has a favorite saying, you all estimate the impact of technology in the short term, but you completely forget the impact of technology in the long run. When patient portals came, I was doing my informatics fellowship in 2003, we thought oh my god, patient portals are a no-brainer within five years everyone would have it. It is coming closer to that, but it is 20 years right now it is still taking time. On the other hand some things happen faster than others, right?
If I have to see what things will for sure happen in five years, I think augmentation through AI for visualization is given. That is going to be not a good practice if it doesn’t have it. Digital care in terms of pre and post procedure, I mean we just gave a sheet of paper to our patient for colonoscopy and 50% of the patients forget where they have kept the paper sheet before they come for the colonoscopy, one in four patients have it with them, right? 20-30% of the patients never come back in the right time, we have no way to recall them, especially in academic centers. With the initiative with AGA for transformation endoscopy, completely that is going to be automated. So, all our practices will not only be seamless but will be of the same standard in the digital standard, not just clinical protocol standard but digital protocol standard will be similar and that is where societies will have a big role to play.
Research will become much more global and much more national. Most of the study that we are doing are one-centered, two centers, every time retrospective, they’re going to be platform registries for mass populations very much like Stop COVID NYC and we are going to have like 300,000 people, GI people in the gird maybe or you know 20,000 or 30,000 IBD registry globally or nationally. So, we can actually do better research, better recruitment, I think it is going to be fascinating time. There will be little bit of role changing for gastroenterologists and I think that’s great. There’s lot of… Vinod Khosla talks on you know, upskilling. So, technology enables a generalist to become a specialist and a specialist to become a super-specialist or more importantly everyone can do more than the top of their license with technology enabling and I think it will become a much better population health. Delivery care experts will be able to provide not just the science of the medicine but also care delivery is sent much more better in our practice and they will become much better national and global researchers by adopting this in a meaningful manner.
Praveen Suthrum: Excellent. Stay safe, you and your team and thank you so much Dr. Ashish Atreja.
By Praveen Suthrum, President & Co-Founder, NextServices.