Designing for Health: Aditi U Joshi, MD [Podcast]

Show Notes:

[00:00] Intros

[00:23] From emergency medicine to digital health

[01:18] Early days of Telehealth

[03:27] Framework for Telehealth success

[05:55] Patient readiness

[10:47] Building “digital empathy”

[14:28] Generational and cultural considerations

[21:01] Driving adoption and scaling digital tools

[28:42] Aditi’s favorite well-designed thing

[29:58] Outros

Transcript:

Dr. Craig Joseph: Doctor Joshi, welcome to the podcast. Where do we find you today? What continent are you on?

Dr. Aditi U. Joshi: Hi. Thanks for having me. Today I am in Chicago, so I am stateside.

Dr. Craig Joseph: Okay. And I ask because you do spend a lot of time on a different continent.

Dr. Aditi U. Joshi: Yep. I live in Paris, actually.

Dr. Craig Joseph: Well, why don't you tell us a little bit about yourself and what you do now?

I wrote a book on telehealth called Telehealth Success. And just recently, this last year, opened a new company on clinical adoption of digital tools. And that is what I am working on right now.

Dr. Craig Joseph: That is a lot. And I am tired of just contemplating some of that. Let me. I must have misheard you. I think you said you started in telehealth, telemedicine in 2013. That cannot be possible.

Dr. Aditi U. Joshi: Oh, it's possible. And I'm, you know; I would say it was very early. That is true. I'm one of the earlier ones, but there were other people who were there already. But it was a very tight knit group. We all know each other because there weren't a lot of us.

Dr. Craig Joseph: So, what was it like back then? What was the technology when you were kind of starting out? Was that a limit?

Dr. Aditi U. Joshi: You know, it's funny because people always ask or assume this part is the problem. And I got to tell you; we're not actually using much more sophisticated tools now for telemedicine visits than we were then. Basically, just trying to connect two people, two parties over telemedicine. It's actually not that difficult to do, right? We have all the tools and technologies to do that and every other part of our life. And so, in general, it really isn't that different. We haven't changed it all that much. There's a couple more bells and whistles that obviously we can talk about more, but really the barrier was that nobody knew what it was. Patients, doctors, and other clinicians didn't know what it was. There was no reason for people to use it, or they didn't have a reason. They thought they needed to use it. Reimbursement, of course, is the problem. You couldn't pay for it. So why would doctors add more things to their services that were unpaid when they do a lot of unpaid services that we both know already? And then, of course, it was just about getting the right regulations and making it safe and making people feel safe doing it in all ways. Whether it was, you know, avoiding fraud, having the right laws in place, all those things. And, you know, if we look at it today, we've solved a lot of that, but not all of it.

Dr. Craig Joseph: Certainly, we have run into a little bump with telehealth being reimbursed. But hopefully these problems will look back on them and say, ha, that was funny. Remember when we didn't pay for telehealth? Going back to, you know, you mentioned telehealth success, your book on how to thrive in the new age of remote care. What are some of the secrets that you learned? I assume you kind of must have stumbled into them.

Dr. Aditi U. Joshi: For anybody who's listening or yourself as well, anything that you start that's new and there's no criteria around it, you do just sort of stumble around until you figure it out. And then when you do figure it out and create something organized, like we put in the framework for telehealth success, it seems very obvious. But no, it was not. It was not something that was organized like that in the beginning. But basically, the idea behind that framework is how do you actually build out program successfully? What are the parts that you need to think about and what are the components of each of those parts? So, it's broken down into five sections.

The first being patient because that's obviously the lens you want to think through the quality of. Is it how do you get them to understand it, who are the patients you're going to be serving, etc.

The second is clinicians, because telemedicine isn't just practiced by doctors or nurses. Everybody does it, right? Especially when the reimbursement came around, lots of different groups. And so it's about, you know, how do you do it effectively and safely? What is the evidence behind it? But then also you're building it out. What's leadership look like? How do you actually get people to adopt it? What are those structures that you need in place. And we could come back to it because of all of these. I just don't think that this is the one. I think we solved the least.

Then there's a tech, and I alluded to that a little bit, is finding the right tech and what's out there. And in general, you know, we have enough tech. We have more tech than we're actually using in health care. And so but it's really got to find the right one for the program that it's the finance, the reimbursement. And this is not just, you know, we're looking at a US based lens when you and I are talking. But generally it's what kind of health system do you have? What is the basis in the premise of your health system, and how do you take that and make sure that it's paid for and fits within the system that you're working within?

And then lastly, it's compliance, which ended up being a catchall for a lot of different things. But it's like regulation, fraud, malpractice. How do you make sure that all the little legal parts that you need to know about are taken care of as well? And so that's what the framework is as general.

Dr. Craig Joseph: Let's, you know, break that down a little bit. The first section was patients. What were you kind of most surprised about in terms of patient's readiness or patients ability to get on a telemedicine visit? Or are they just kind of like, no, this seems weird. I would like to drive to the doctor's office or, you know, what are the questions that that people kind of used to come up with, or maybe still do?

Dr. Aditi U. Joshi: This is a good question, because I'll say I tell a lot of these stories. I saw a lot of telemedicine patients, and some of them are just really funny. But I'll give you some examples that really encapsulate how patients do. I will say, overall, patients like it a lot more than I think even doctors expect them to. So, I have seen people calling me wherever they were. You know, a lot of it was, oh, I've never done this before.

So, this woman called me from her office cubicle, and everybody in her office was, like, standing behind her because they were fascinated by this entire concept, and they were like, oh, my God, is this a real doctor that you're speaking to? And I was like, hi, everybody. This is actually a medical encounter. You can't be sitting in the middle of everywhere.

Dr. Craig Joseph: Wow. Okay. And did they leave or did they want to stay and listen to her medical problems being described?

Dr. Aditi U. Joshi: No, they actually understood. They're like, “oh, yeah, of course it's medicine. It's health care.” And so, even the patient understood it. This is just a funny example, you know, but this is part of, like when I was teaching students or residents or other doctors, I would say, you have to you have you have to set that standard. You have to go there even though it is not something that is normalized yet. You have to set the standard and say it is a medical encounter. But that's what this would extend to, you know, people sitting in restaurants or just be walking on down the street or driving, right? I would tell them to pull over or I would say, go somewhere that you feel comfortable, that there's nobody around to listen because it's the real, you know, health care encounter. So this is just to give you an example that people were really comfortable with it. And some of the other things I saw that I think are really important on the patient aspect is how helpful it was to some people, and especially when they were in places where, you know, maybe the clinic that they would have to go to if they needed to go see a doctor right then was really far away.

So they would call just to get triage, like, do I need to go now? This is something I can wait. And that was helpful information for them. I saw patients I remember and I've seen I saw more than one of these. There were, like, LGBTQ youths who had questions about sexual health, but they didn't feel comfortable going into the clinic in their in their town or whatever because they didn't want to be outed. They didn't want people to know.

And there are a number of examples like this of where people just felt safer doing it, where it was somebody else, somewhere outside of there. And so it really gives you an idea of like how it helps it access culturally competent care that patients really, really found it useful. But it also makes you realize there's it's a real responsibility, right? You have to also deliver that care as well. And so in general the patients really took to it.

Dr. Craig Joseph: All right. So the other side is the clinician. Was there anything surprising on that side when you were teaching or interacting with your colleagues?

Dr. Aditi U. Joshi: What I would always tell people and you know, I saw a lot of this is that just there was two camps, right? There's going to be the one group who thinks this is going to be really easy. And so there's not much that I have to think through when I set this up. And I see patients and there's going to be some who take to it really easily because they've either grown up on technology or they understand the concept, but a lot of them were like, oh, this is a little bit more awkward than I thought it would be. And so they just had to regulate that and understand what it means and make sure that they were doing the same types of, you know, tricks about listening and making sure the patient understood what they were saying. And to read through a camera what was going on. So it took a little bit of just getting used to that. And then on the other side are people who are really afraid of it, right? They're like, well, it can't be safe. There's no way to do an exam. There's no way to make sure that people understand what you're saying. And in that group, actually, I find that honestly easier because I could say, listen, try it. Let me tell you how to do it effectively.

And even if they won't come with me 100%, I could get them at least 70 to 75. You know, they might be like, I'm not doing a neuro exam, but I get it, okay? I see how I can do a skin exam and a musculoskeletal exam and history. But yeah, I'm not coming with you all the way, but I will come with you this way because I understand it. And so between those, I mean, the point is really that depending on what you're trying to do over that is going to really inform what you have to learn, what you have to teach and what you have to do for your patients. But we now have enough ways to really cater to everybody, right? That's trying to do it. There are enough things that we can do even without the tools that we have now. We have enough tricks that we've learned to be able to help anybody do at least some of their exam and evaluation. Now, the second trick, of course, is convincing everybody to do it right.

Dr. Craig Joseph: Let me dig in on just a thing that I've seen some doctors struggle with, which is that kind of bedside manner. But I used to joke that I got honors because I was able to sit forward in my chair and nod up and down empathetically. It's hard to do that. It's a joke, but there's a little bit of truth in there. How do you kind of make that bond when someone could be in a different part of the state, or they could be in their car or sitting on the side of the road?

Dr. Aditi U. Joshi: Oh yeah. And we can actually absolutely do that. So we call it digital empathy. Originally when I started they used to call a website manner. I will tell you, I will tell everybody I do not like that term. I actually just don't like the way it sounds. I prefer digital empathy because I think it's more all encompassing and it just sounds better to me. I always take it in steps, right? Because if you put that system in place, it's always easier versus just setting yourself up for success, right? So for example, you're talking about sitting forward. Well, if that's going to be something that's helpful for patients to see that you're engaged, pick a chair and pick a place that you're sitting that has a setup that allows you to do that. That looks like you're sitting up straight, that you're engaged in that person. You have the right lighting, the right sound, anything that's going to help you to do before actual visit. And then when you're actually in it, there’s going to be people who are better at bedside manner just naturally.

Right. That's true. And we've seen it in medical school. We see that in training, there's going to be people who are better at digital empathy. Just by those things, but everybody can learn it. And it's the same type of trick. Right. So, the only thing you have to think about is what the patient can actually see. You know, we famously say you want to make sure you look at the camera, you want to be able to see most your shoulders have some hand gestures if they can see it, nodding all of the things that are cues that you're listening to the patient, there are going to be a couple of things that are a little bit different. You know, the thing about the looking into the camera, too, I find that that probably is not as important as we think, because the way that even that all of us look at our screens, people can understand that that person is looking at you, even if they're not looking at the camera, like may be doing right now compared to it. Right?

So, people understand that what it is more important is that you're there and it's you're square and it looks like you're actually engaged to what they're saying and what they're doing. Other things that I will do is, and because it is different, it is that you have to actually make sure that you are answering all their questions before you leave because you can't walk back into the room. Right? So, I will actually spend extra time answering questions, trying to understand what it is they're really worried about. And that's really you don't just pick up like here. Right. This is a skill that you have to pick up. Also when you're in person. But there's a number of ways to go through that. But that's really one thing you have to remember that you're not going to be able to come back in. So make sure you get that right.

And then you have to also, you know what I do. And I think that makes it even more personal to the person on the other end. I'll say, okay, listen, you know, if I have to do a physical exam, sometimes I'll ask them to get involved or I'll ask a family member to get involved, and then I'll explain to them why I'm doing it. Sometimes I'll show them on myself what to do, and then I'll explain to them what I'm looking for and why. And I have found that patients are like, oh, well, now I understand why you're asking me to do this. I understand what you're looking for. And now I understand why my doctor does it in person, and I didn't. That actually makes people feel more connected because they are connected to me and what I'm trying to tell them as a physician. And so I think that assuming you can't connect over video is difficult. I don't think that's true. I think there's absolutely a way to do it. Now, of course, telemedicine by definition also includes audio. And it also includes chat, which is a different story. It's obviously easier to connect over video. But you know, there are some tips and tricks for doing it on phone and chat, but it's going to automate it.

Dr. Craig Joseph: I can imagine because chatting is kind of generational. Or are there, you know, some things that you need to do for more of an older group?

Dr. Aditi U. Joshi: Yeah. So I will say that all groups use telemedicine. I will say, you know, initially I would and I still see there's a lot of when people are in, maybe they're elderly or they don't use their phones as often. Often they would have some family member with them who was helping them through it, showing them what to do. And most of them would be like, oh, okay, we understand because I think that once you present it again, if you come in and say this is a medical encounter, they respond in that kind. But then in that way it is important to be more formal and just statistically, they're not the group that loves it the most. They aren't. But you know, that's fine, but that's okay. We don't need everyone to use it. You know, I would say also, it's kind of a myth that baby boomers don't know technology. They do. They use it a lot. And so you will find them also wanting to do it.

But again it really depends on how their doctor, because there's a lot of trust in their doctor still in this population. what are their doctors offering them and what do they find that is useful? They don't trust you if their doctor doesn't trust you and they have that experience, they're not going to come back. And then secondly, now when we talk about like younger generations, the tech is not a problem for them. But what ends up happening is just that they don't necessarily have a primary care physician. It may be piecemeal care. So, the challenge there is not the technology. It's actually trying to put together a comprehensive health picture because they're not using it.

Now, those are just the those are just from age groups. Right. If we consider, you know, going back to the difference between culturally competent care, you're going to see a lot of groups out there, a lot of companies out there that are catering to specific groups just to get them the type of care that they may not feel comfortable getting right there. And I give the example of LGBTQ, there's companies that work specifically with trans rights to work with black Americans, with Latin Americans, or people speak and then others with the, you know, language. There's so many different groups because their whole premise is that every group is going to need something different. And the beauty of using telemedicine is that you can actually offer this, right, because you can offer it to somebody who's not in the same area as two different groups or you of the age, then you have all these other groups together, which obviously people are more than just one.

Dr. Craig Joseph: So, what about chronic care? Often in my experiences as a primary care doctor, they would know as much, sometimes more than me, about the condition. Seems like that would be an excellent use case for telemedicine. And that. Hey, we don't have a lot of explanations from you about what's going on. I read this study, and I want to talk to you about it because I think it's relevant to my care. Have you seen anything like that, or is that not as common?

Dr. Aditi U. Joshi: I think that's a great example, especially because anybody who works with insulin dependent diabetics, especially those who have had it since childhood, they need very specific specialists, right? Diabetes, even because they know more than most of the anyone else on this particular topic.

And so what I've seen that really helps is, again, having access to specialists that they may not, in the past or it was hard to get an appointment for them. Now, this ends up not being necessarily a problem for somebody who lives in a large city, and they can see somebody, or they live near a large institution that works with this. But often that cases, this doesn't happen. And so you can actually use telemedicine to connect with people who maybe already are their patients, but have to come in two hours for appointments. And nowadays they don't have to do that. They can actually check in, like for example, about just using and checking in for questions about a study or a new medication or a new process. They can do that. And then it also allows for specialists who may want to work with those populations. And really, you know, treat people who need that type of care that they maybe don't need to do, you know, general endocrinology anymore.

They can see specifically people with diabetes. They'd have a big enough patient population to do that. So, you could think of it as one aspect. And then if you think about the type of telemedicine you can do, adding devices like remote patient monitors and remote therapeutic monitors and those type of programs, they're really geared toward people with chronic diseases, such as diabetes or congestive heart failure, because they can be at home and the data from their blood glucose monitor or, you know, CHF, their weight, their have blood pressure, etc. can be sent to their doctor and then they can intervene before things go really poorly and they end up in the hospital.

So I see there's like two different ways to do it, right. So they can have that data real time. Because as we all know, people's health care doesn't go away. It's not only when they're in a clinic in the hospital, it's actually everywhere else. And so this allows you to actually get the care anytime or when you need it.

Dr. Craig Joseph: That makes sense. I like the idea that you just said, hey, if you're a diabetic allergist, you might be able to just see a lot more. You could see just the patients that you can help the most. Do you generally see that physicians can see more patients in a small amount of time? Generally, you're not waiting for patients to be roomed.

Dr. Aditi U. Joshi: I'm not even going to make this out. I'll tell you. The research shows that most telemedicine visits are shorter than the time allotted for them, except in primary care. But that's because I think primary care visits are in general, probably too short for the time allotted. But in general, across the board, they generally show that it's shorter. And I think it is because there's no distractions. It does take less time to get room patients because they know that they're there on the video. They have like their questions maybe ready or you have more targeted time. You can really get into what their actual issues are without people coming in and out. And it's funny too, because I think about when even if you're in a clinic and people are not coming in and out of your room, there just feels like more distractions in a clinic because, you know, there's a lot of apparatus.

You're sitting in front of your EMR and you can see them typing. So you think that you have to wait to ask a question. Whereas when I'm doing a telemedicine visit, even if I'm typing, they may not see me typing, but I'm talking to them or I'm typing or, you know, whatever I'm doing it after. So they don't actually have to see that. So it's not as if there's this gap, also, that they're watching happen without realizing that they're, you know, that it's a distraction at all. And I like notice this too, right? Because when I go to the doctor, I'm like, wait, I'm waiting for them to stop, even though they're still speaking to me.

Dr. Craig Joseph: You've just started. You've just launched a company called Ardexia. And so why don't you tell us, first of all, where'd you get the name? And secondly, what are you hoping to do with Ardexia?

Dr. Aditi U. Joshi: Oh my gosh, the name. I had to think about it a long time, and really, I was looking at words that had some meaning to me. And so it's essentially a mix of nexus, like a feeling of connection and then something that's really ardent because it's about like things, what we're passionate about. And I do think that in general, in medicine, in clinicians, we are passionate about science and medicine and whatever it is that we're doing. Otherwise, you know, honestly, it's not really something we probably want to do, right? There has to be some labor love in it.

But the idea behind this was after all these experiences I've had and I was mentioning within that framework of the telehealth access, it still occurs to me that we still tend to see that clinicians are not feeling comfortable using a lot of digital tools. We've invested in a lot of digital tools. We have all these telemedicine platforms. Yeah, most of the actual adoption sits about 20%. But in most health systems, which honestly, it's not even just that there's executives worried that there's money left on the table. Certainly it is. But it's also that you have all these patients, patients really love it and they find a lot of benefit from it.

I mean, across the board we're not able to see the right patients, not able to offer the services. It has effects on health equity. There's a lot of reasons that we want to improve this adoption. And so for me, I thought, okay, well, what can I do about this? And I'll say that from the beginning, one of the things I had to do the most was convince my colleagues that this is something that they want to do. And just in all of the leadership positions I've had or whenever I've built programs, whether it was in the U.S. or in other parts of the world, this is a common problem. And so our Dax is really built about how do we solve that problem, just so that all of the digital tools, all the technology we have, we can use effectively so that people who have invested in it, they get their ROI. But from my perspective, what I want to actually do is make it so that when clinicians, physicians are using it, they can use it without feeling like it's a burden.

Dr. Craig Joseph: How does a health care system do better with adoption? What are some of the secrets? I know you started a company to give advice, but I'm trying to get all the good advice now for free so people don't have to engage. But, what are some of those high-level kind of diamonds that that you can give away?

Dr. Aditi U. Joshi: I'll give you an example of an idea where the idea partially came from. If somebody came to me and asked me saying they had a big telemedicine program and they couldn't get their doctors to use it, this is not a US-based company, by the way. It was a global company. And their essential question was, oh, can you set up a training to fix this? And, you know, I just had sat and thought about this. And I will also state that training is incredibly important. You want people to be able to understand the tool effectively, to be able to do it, not just the technology, but what goes into a good visit. So what is the evidence-based visit? All of those things. And I realize that's not going to solve the problem. And so aside from that, you know, it's really looking at what is where are the actual pain points? And so you have to sit there and actually look at the process of the protocol. And what's important about it is that you're not doing it when somebody understands they're being watched and being trained on this project, it has to be something that stops them from using it as physicians and other clinicians, too.

But I'm speaking from physician because I know that from the physician standpoint, we tend to be good about figuring workarounds. Just because we have to get what we need to get done. We don't always know what that is. And so this idea is like finding those pain points, for one. And so that actually is probably the problem. That is the hardest part to do. And then the other parts would be how do you create a leadership team that is going to support that, to sustain it? And who are the right people to do it, which takes a very specific type of leader and leadership team to do that. Then you also need to think through how do you make sure that there is, you can call it a lot of different things. You can call it QA, API evidence-based medicine, whatever you want to call it. But it's like, how do you actually have a process in place to continue that cycle to constantly improve? And then lastly is the human component. You have to really think through what that is, what the barriers are for that particular group, because it's not always exactly the same. You know, they're going to be general themes, but it's not always exactly the same. And so the idea here is like looking and doing this, validating this entire process. And then actually my goal is to automate it because otherwise it won't scale.

Dr. Craig Joseph: I'm glad you brought up scaling because that's what I kept thinking about. Oftentimes these are started as pilot projects. And hey, we're going to roll this out. How do you scale so that you can get adoption throughout the organization. Or if it's not primary care, just specialist? That still seems like a big overwhelming problem.

Dr. Aditi U. Joshi: Yes it is. And part of it is going to be exactly the part that I said that's the most difficult is finding the actual pain points, is automating how you get that data. And then from there, a lot of that scaling is going to be done in tandem, right? If you're going to be able to set those things up, and those processes tend to be already existing within health systems, they're not actually going to be different, just going to be specific to whatever the pain points that you find are. And then it's really just fixing it. I think everybody in any field is always frustrated when they know that something isn't working for them, but they don't feel like people who are in charge or dictating what they have to do are listening to that. And so, yeah, there is a lot of psychology in that. And it's not even about, you know, I think it's less like, oh, well, I'm better at this or I am different at this. It's like no one is listening to what I'm trying to tell you. And I think that's really the important part of it. And I think that's what missing from a lot of it.

And I do think that there's a lot of discussion about, oh, you had two clinicians on teams. You got to listen to doctors, what they're saying. But I end up there's two problems that end up making it harder to do. Is that one, nobody's exactly sure what that bit. Right. Like what clinician do you listen to and where in what aspect. Like what part of it do you understand. And then second, we're not always aware of the pain points that we have. Even if you're somebody who is in trenches working this day in and day out, and I can speak to that from my own experience, like something that I thought maybe was a problem, maybe not. The problem itself. Right. And so when we're all trying to get this data from each other and people I think do want to listen to doctors and clinicians about what happens, we just don't know if it's the right data. Right. So that's what I am also working on is like getting that right data. But you can actually fix the real problem.

Dr. Craig Joseph: I for one, am glad that you started this company and I look forward to you kind of solving some of these problems because they are big, hairy, ugly problems. And I suspect once you've seen them at one institution, you've seen them at one institution, and it's the culture and particular technology and physician mix that, that you see, from organization or organization, it's going to make a little more complicated, than some other project.

Dr. Aditi U. Joshi: Yes. It's overly complicated. I will say that, when I was building this out, it's like, well, I've really taken on something very ambitious, but, you know, like, you think about your life and like, in sections, I've had this really interesting experience. I've been an E.R. doctor for 14 years, and now it's like, what I want to do for the next decade or two is what I'm going to do.

Dr. Craig Joseph: I love it. Let me ask you the last question, and we always try to ask the same question, which is talking about design. And is there something, you know, you've been designing telehealth programs. Is there something that's so well designed in your life that it brings you joy whenever you interact with it?

Dr. Aditi U. Joshi: Yes. And you're going to laugh a little bit because it's something that I thought about this question when you did it, but I was like, what do I use a lot of that I really love the design? Well, I bought this backpack in Paris, and it's made all from recycled material. So obviously I feel a lot like very good about myself using all types of material. But the way that it's set up, you know, it has like an incredible space for my laptop. It has wide straps and then it also has a number of small pouches so that I can put my wires in one. I can put my medications when I travel in another, I can put my phone in the third one. And I really like it because for me, in the past, when I and I'm sure we all travel a lot, but I always seem to put things in little packages and there's just it's just a mess everywhere. I can never find my wires and I always feel like it's lost. But this way, the way that they have it, where there's like pouches sitting on the outside of the backpack itself. So it's like attached to it. I can find everything really, really easily, and it makes my travel so much more enjoyable because I feel like I'm not, always worried about where everything is. And so, I really love that backpack.

Dr. Craig Joseph: What is the name of this backpack?

Dr. Aditi U. Joshi: Okay, shout out Cabaia. It's the AB air.

Dr. Craig Joseph: That's great. And often it's those little tiny details like lots of little pockets, not big pockets, but little pockets because that's what you need. It has been a pleasure talking with you. I've certainly learned a lot. And as I mentioned, I look forward to all the success that'll come with your company. Thank you for kind of spearheading this. Starting off telehealth and way before the pandemic made it much easier. So, appreciate all the learnings that you're sharing with the rest of us as we figure our way through these complicated workflows and technology decisions. So, thank you again.

Dr. Aditi U. Joshi: Thank you. Craig, it’s a pleasure to be here.