Designing for Health: Interview with Eve Cunningham, MD [Podcast]

Show Notes:

[00:00] Intros

[00:52] Value-based care and early innovation

[02:10] Challenges faced during and after the pandemic

[05:34] Remote patient monitoring

[10:05] Hospital-at-home challenges

[14:05] Cadence’s comprehensive care model

[27:35] Customization in digital care and preferences

[33:16] Governance and protocol

[37:29] Eve's favorite well-designed thing

[38:58] Outros

Transcript:

Dr. Craig Joseph: Eve Cunningham. It is great to have you on the podcast. Where do we find you today?

Dr. Eve Cunningham: I'm at home.

Dr. Craig Joseph: In your home office?

Dr. Eve Cunningham: I'm in my home office, yes, but I have been traveling. I was just in Chicago last week for Beckers. That was, that was a fun event. So, I get on the road here and there.

Dr. Craig Joseph: Let's talk about your background. You are an obstetrician gynecologist, I believe.

Dr. Eve Cunningham: Yes.

Dr. Craig Joseph: How did you get to where you are now? Let's just let me have you talk.

Dr. Eve Cunningham: I'm an OB-GYN physician by training, and I thought that's what I was going to do. You know, when I went to medical school and residency, I thought I was just going to be delivering babies and doing hysterectomies at this point in my career. But somehow, after I left, I did my residency at Kaiser Permanente. So, I really learned value-based care through my training, which was really cool, and then ended up at what is now Virginia mason, Franciscan Health and Spirit. At the time, it was called DEI as an OB-GYN, working there for a number of years and started getting the pull into clinical leadership. So, you know, initially they tap you for committee, then, “hey, do you want to be a medical director?”.

And eventually got to a place where I was leading a very large portion of, the multi-specialty medical group there. I was the division chief for women's Children's, the Urgent Cares. I had virtual care under me, which that was before Covid. And virtual care was just a very small thing. But we were doing innovation there and then, you know, eventually got recruited to go to Providence to lead one of the multi-specialty medical groups. So I became a CMO of a medical group, had about 350 docs and 25 specialties, five DME program. So really cut my teeth in physician leadership, clinical leadership, and after a couple of years at Providence, started to really kind of get especially during Covid. I was just really frustrated with the experience the clinicians were having. Like, I felt like I was like a mouthpiece and I was just trying to like, cheer everybody on. I just didn't really have any decision making capabilities or ability to improve the, technology experience that the clinicians were having, on the front lines. Providence was making a lot of investments in technology and innovation. And so I kind of worked my way over to the corporate development team, convinced them that they needed a doctor in their shop. And that I was the right doctor to be in their shop.

Dr. Craig Joseph: The shop, you know, this is a big multi-state health care system. How come you had to convince them that they needed a doctor to be at least peripherally involved?

Dr. Eve Cunningham: They were making a lot of investments in technology or taking bets on some incubation and innovations, and it wasn't really translating to a better experience for the clinicians or improving the efficiency of care. And of course, as a physician leader and a clinician, you identify so many opportunities to improve care. So there's so many different ways you can improve care delivery. We have so many ideas, but those ideas weren't really translating to the folks that were making these decisions. And so they're not clinical. They're business people. Corporate development is like, you know, they have an a keen eye on some of the things that are happening in the market where there might be financial investment opportunities or partnership opportunities. But some of the details of those opportunities require a clinical lens and a clinical input. And so I kind of started out sort of volunteering for them as an advisor. I was still working as the chief medical officer, but I'm like, let me show you how I can be helpful. And so I did that for about six months and helped them with several of their incubation, several of the things that they were working on, for partnership strategy, they've spun out technology services company called Tag Area.

So, I was advising that group a lot, and they realized that I brought value to the team and that I could provide them with really good strategic insight and input. And I had a pretty broad experience, not just as a front line clinician, but also clinical operations and revenue cycle and the O.R. and, you know, service line delivery and things like that. And I had other skillsets that they found could be leveraged. And so that's why they created a role for me. Yeah.

Dr. Craig Joseph: I love it. I think the one thing that was missing from your background was technology.

Dr. Eve Cunningham: I didn't come from informatics or the traditional technology background, but let me tell you, I went to the school of hard knocks of technology because I went over them to corporate development, and I just was like a sponge. I learned everything I could, then started incubating a product at Providence. That's a platform. It's a clinical decision support platform called med Pearl that's still there today. And then eventually, after a year or two on that corporate development team, the leader asked me to take over leadership of the entire virtual care and digital health portfolio, which was all of our inpatient telemedicine, virtual nursing, hospital at home and remote patient monitoring. And that is when I came across cadence, which is the company that I'm now the chief medical officer of today.

And we partnered with cadence. We brought them into Providence and began to scale remote patient monitoring across Providence. So, kind of a convoluted story, but I didn't come up through the traditional way, but I learned a ton about technology. And just with is, you know, full throttle as I could in trying to learn everything that I possibly could about the industry and what was happening so I could act as a translator between clinical and engineering and product.

Dr. Craig Joseph: I love it. And that is kind of like the traditional IT physician leadership, you know, CMO type role. Right? Just have one foot in the clinical world and one foot in the IT world. But you also had that operations experience, which a lot of physicians don't have.

Dr. Eve Cunningham: A lot of chemicals, do not have experience leading, medical groups and, and operations. So I don't have as much, in-depth knowledge, I guess I would say of the EMR, though I do know a lot about the EMR. I wouldn't I don't know as much as an, as a CMO, probably, but I know quite a bit. But I had that experience leading positions, launching clinics, launching programs and things like that that I think has been quite useful.

Dr. Craig Joseph: What were some of the things that shocked you? Maybe, our learnings, from, from a technology perspective, obviously, you know, how to lead physicians and, and get them to try to at least point them in the same direction. Anything that when you started to get more on the tech side. But as you mentioned, you maybe you're not a CMO, but you're you were right up there. What was different than what you thought from the outside looking in.

Dr. Eve Cunningham: So, you know, I started on the journey about five years ago and there was so much investment. I mean, 2021 was just like, oh, massive valuations and investments in technologies that were going to change the world. And then when you kind of went and looked under the hood of like, what was there? There wasn't much, there was a lot of noise and a lot of crap on the market, frankly. I mean, it was like overwhelming. And we're starting to see that now with AI products to where they say they can do a lot of things, but what they actually do is quite minimal. And so, I think to me what a little bit shocking was kind of from an integrity perspective. Like as a clinician, when you say you do something, when you say you throw out a fact or a data point or you say that, hey, we can do X, Y, and Z like you do it.

You don't say, I'm a surgeon that can do something that you don't have a skill set doing. And so, it was kind of shocking to me, like the level of vaporware like that was in existence in the industry. That was really surprising to me. And I was naive in the beginning, to some degree, in the sense that, like, I didn't realize that was like how it was. Well, I think I took some learnings and some learnings over time. Now I feel like I can sniff that out, like immediately. But, you know, as clinicians, you're not like you take people usually as you take things at face value just because that's like our expertise, our skill set that we communicate and collaborate with each other about. We're very transparent. You know.

Dr. Craig Joseph: And that's something that CM, iOS and KaiOS regularly run into, which is the, you know, the division chief for Gastroenterology calls up and says, hey, we bought this product, and we want to connect it into the EHR.

Dr. Eve Cunningham: You know, my eyes have fatigued over that because they've been burned. So many of them. So, when I came I didn't come from that route. So, I didn't have that perspective as much. And before I've learned, I feel like I think like a CMO and a lot of ways when it comes to, you know, snuffing out. But then again, if you can cut through that noise, there's actually some really incredible and transformational products, and services that are coming out on the market that really are making an incredible impact on care delivery.

Dr. Craig Joseph: What did you, you know, discover during the pandemic where? Yeah, right before the pandemic, all of this was, well, we could do this and we could do that, but payers won't pay for it. So, it doesn't really matter anyway to oh my God, we need to get all the patients out of the hospital and home as fast as possible. Were there any high-level learnings from that kind of, dealing with that?

Dr. Eve Cunningham: Yeah. I mean, the pandemic, like, catapulted us into this world, but then we, like, stitched it together with not the most optimal workflows and technology decisions. And obviously then also the market matured. And so, there's been like new solutions where you're like, shoot. If we had waited three years, we would integrate with that. But now we're already integrated with this other thing, and we're stuck, at least until we can get it into a prioritization workstream again. But I would say, you know, we rolled out of a hospital at home. Hospital of home, man, I feel really bad. I was just at the Becker's conference last week, and they were talking about the government shutdown and like all these hospitals at home, massive investments that health systems have made and building out the infrastructure for hospital health, Providence was one of them.

You know, we spent quite a bit standing up, and we're seeing really good signals. It takes a while to scale a hospital at home. They're just logistically and operationally extremely complex. And then there's the whole change of management aspect. That is like you're doing change management with the hospitalist, the Ed docs, the nursing staff, and the patients with compliant billing in the finance team. Like it's like all across the board, change management. You know, they all having to shut down or pause their operation. And it's really hard to do start stop, start, stop. So, a lot of health systems are hesitant to invest in the hospital and home infrastructure until there's more stability in the reimbursement model. I mean, why would they do it otherwise for remote patient monitoring? That was an easier one to do. Health systems hadn't really figured out how to scale these programs and get reimbursed for them very easily, because there is quite a bit of a science to being able to do that well. And you also have to have the workforce that can actually process the data and the information coming in. But during Covid, we had our Covid home monitoring program at Providence.

We had almost 30,000 patients that we took care of. We knew that remote patient care for managing Covid was an excellent mechanism to reach these patients. When we didn't have a lot of capacity to bring them in, we wanted to keep them out of the hospital. So we knew that approach would work. And what we needed was a partner that could help us scale it in a financially sustainable way for other use cases. And that's why cadence became like a really compelling company for us to bring in, because all the remote patient monitoring programs and companies that were out there were basically they had amazing technology that was really smart technology showing the devices and how their data could come in. But they were technology only companies, and technology was only part of the problem. We also had a people problem. Who is going to process all of this data? Who is going to react to it? Who is going to make changes to the patient regimen in between care? And how are we going to pay for it? And so what cadence did was cadence said, hey, we have our technology platform, we have our logistics, our operations, our devices, like a whole enrollment machine to getting patients enrolled in the program.

And oh, by the way, we have this medical group and we have clinicians who will act as an extension to your primary care physicians, your cardiologist, your nephrologist, your endocrinologist. They will act as an extension with nurse practitioners, nurses, health coaches, and with mutually agreed upon protocols. We will titrate medication and we will process all the data. We will react to the alerts. We will titrate medications. We will order labs based on these mutually agreed upon protocols. And then we will deeply integrate all of that data information into the EMR, your native EMR. So, your doctors never have to leave the EMR. And they can see what's going on with their patients while we are acting on behalf of them to deliver guideline based care to the patient. And then we'll wrap that all up so that you can bill for those services, and then you don't pay us until you get paid. So, it was financially sustainable. It solved the people's problems. It solved the process problem because we think that the workflow is deeply embedded into the EMR experience and the technology. We provided the technology, as well for the patient. And I was like, that seems like a really winning approach to scaling remote patient monitoring. Health systems don't have a core competency in scaling remote monitoring in a financially sustainable way. They have a core competency in hospital operations, clinic operation. We're building the infrastructure for remote care delivery that is in partnership with health systems.

Dr. Craig Joseph: So, this is not so much hospital-at-home as a long-term chronic care monitoring. Or is it both?

Dr. Eve Cunningham: Our main focus is to try to get our patients enrolled and engaged in the program. Upstream of being in the hospital, right? So, our goal is to prevent the patients from being hospitalized, prevent CHF exacerbations, and prevent stroke from a hypertensive emergency because we get in front of it because we're monitoring these patients on a daily basis. So, we start with a more we started with a more ambulatory care enrollment focused approach. That being said, as we started to grow and scale, the program started publishing. Our data started showing the clinical impact that we were making, which is a pretty incredible clinical impact. We got the attention of the American Heart Association and they said, look, what you guys are doing is really interesting and seems to be impactful. Why we get phone calls every day from hospitals talking to us about readmission penalties, readmit patients with CHF, hypertension that are getting admitted to the hospital, and they need some type of a post-discharge solution so that when these patients get discharged from the hospital, that we're doing everything we can to prevent them from bouncing back. And we think what you guys are doing is a really good approach to solving that problem. So let's partner up and launch a national remote care transitional care program for CHF, hypertension, and some of these other disease states. So, we've partnered up with the HRA. So, we're not just ambulatory. We're also doing some transitional care Post-discharge. And we just launched that last month. The way that we manage chronic disease in traditional care delivery is it's not working pretty horrible.

Dr. Craig Joseph: Pretty horrible.

Dr. Eve Cunningham: I mean, it's not it's not because the doctors don't care or that we're not doing it like we're not trying to do the best job we can. But I read a statistic recently that said, if a primary care physician was going to pay for a practice guideline, directed care, like in every visit where they were getting every patient, the counseling they get, getting them to guidelines for all the different things that they have going on. It would be 26 hours a day per clinic. So there has to be some other mechanism to support and enhance the care that they're providing. And so, we see ourselves as an extension of what they're trying to do for their patients.

Dr. Craig Joseph: I love it. Let's just, for the second think, hey, I'm a patient of a health system that you work with, and I have CHF. And so somehow at some point, I'm going to be referred to by my cardiologist or my primary care doctor. Is that how it works?

Dr. Eve Cunningham: We always feel like the primary relationship that the patient has is with their PCP, cardiologist, nephrologist, and the health system that serves them. And so, we come in; we have a very tight clinical integration. So, the program is recommended by their primary clinician. They order it for their patients. They get there's a different couple different ways that we can set it up. But we have a, you know, kind of a playbook of how we do the implementation. And we can surface all the patients that could be eligible based on criteria. We have a couple of different ways that we do it, but they make the recommendation and then we once the order is put in, we take on all of the like outreach. So, we have like a whole mechanism of how we do outreach to the patient and educate the patient. And it's co-branded. It's a co-branded program. It's like this is that we just launched at Yale. Last week. It's Yale Connected Care. I mean, powered by cadence. So, if the patient aren't going to respond as well, if they don't understand the connection to their health system, I think that's a very critical piece of the program.

And it's important to the health systems that we serve. This is in partnership with them. I would say that we are writing the book on patient and how you do successful patient engagement, how you do the outreach, how you get the buy in both from the clinician perspective and the patient perspective. I mean, we're pioneers in this space, and we've learned a lot. We're going to be sharing some of those learnings in the paper I shared with you, this coming out in New England Journal of Medicine catalyst, that talks about our the partnership between Providence and Cadence and how we grew the program together and learned a lot together in that process. But just from a patient journey perspective, the order goes in, we start the outreach. We have a whole enrollment team. They and we don't want to, like, overwhelm the patient with messages or overwhelm the patient with phone calls. So, we kind of have a science to how we do the outreach. So, we're not overly plugging the patient or annoying the patient. Once we actually get in contact with the patient, take a lot of time educating the patient about the program.

Why is there value there? One of the sensitive areas is what is my financial responsibility? Most patients don't have a copay. We target mostly Medicare patients or dual enrolled patients. But we do. We have started to add commercial payers as well. And so that is a sensitive issue. We need to make sure that we get the scripting and the and the discussion and expectations very clear with the patient. So, we've spent a lot of time refining and iterating upon that to make sure that it really resonates, both for the patients and for the clinicians, that they feel very well informed. Then if they consent to the program, we have an activation team. So, the patient gets dependent on which disease state. So, right now we have hypertension diabetes and congestive heart failure. And we just launched the Advanced Primary Care Management program. We have chronic care management and the traditional care programs transitional care program with the American Heart Association. So that's kind of our suite of services. But let's just say if it's a remote patient monitoring with a device, we send the patient the device. So, depending on what the disease is, if it's CHF, it's a scale and a blood pressure cuff.

The device comes in a box. It's configured to the identity of the patient. It's cellularly enabled. We don't do Bluetooth. We don't do apps. We don't do apps today. We don't do Bluetooth. We don't do any pairing or any passwords or anything that's required because the average patient is 72 years of age in our program. So, we need to make sure we meet patients where they are. They open up the box; they press the button. The device is connected to cellular, and they check their vital 75% of our patients self-activate. They don't even need us to help them with like turning on their stuff. And then they start receiving messages. We do. We communicate with the patients via text message and via phone. We do not do a lot of video at this point. And that seems to work really well for these patients. We have patients who don't have smartphones or don't even have a cell phone at all. So, we can, from a tech equity perspective, meet them where they are. Most two thirds of our patients live in rural and underserved areas, so we really feel like we're meeting a critical need and a critical gap in access for a lot of folks that are living in places where it's a two-hour drive to come to a clinic.

Dr. Craig Joseph: So, you did answer a bunch of questions I had, right? Which is how do you connect that Bluetooth device? And the answer is it's not a Bluetooth device.

Dr. Eve Cunningham: Keep it super simple. Yeah.

Dr. Craig Joseph: Yeah. Well, that and that's again, lots of companies and folks have stumbled. So now let's switch from the patient journey to the clinician on the other side. So, I'm assuming now they've got the patient has the devices. You're seeing some. Let's stick with the CHF example because I think a lot of us understand CHF. If you're gaining weight that's probably not a good sign. So, something wrong is happening. Someone's engaging. Most likely a nurse or a health coordinators say, are you keeping with your diet? How's the salt intake that kind of question?

Dr. Eve Cunningham: So, we have an alert board because we are now partnered with 20 health systems. So, we have data streaming from patients. We have over 65,000 patients, enrolled in our programs today. We're growing like crazy. So, we're all this data is coming in. And then within our alert board, we have automations and logic that help surface patients based on criteria and based on the disease state. Hey, we've got to outreach to this patient and, like, see what's going on. And so, we have workflows to outreach to the patient. Sometimes it's automations. Hey, can you double check that? Wait, is that really what it was? Then we start, if we validate that there that the patient meets the criteria for the alert. We have different levels of alerts. Some alerts are less concerning, like it's a borderline elevated BP versus something that could indicate hypertensive emergency or something like that. Or a lot of the alerts that we get are for low BP too, or low heart rate. So we're catching things on both and we're doing outreach to the patient. Some patients aren't alerting right. Some patients they're in pretty decent control.

We also have monthly coaching calls with care navigators and health coaches to motivate the patient and help make the patient feel empowered about their health. Educate them. We do a lot of education with patients like what is CHF? What does that mean? I don't understand the disease. I don't understand my medication regimen. A lot of calls, just validating the medication adherence to the medication, tinkering with the medications because there might be symptoms or control issues. So we do a lot of that. And then, like I said, we also have nurse practitioners. Sometimes they're doing scheduled visits with the patients. But we also have what we call a proactive titrations engine, where we are actually scanning the data in the patient's chart. We have these protocols, we have the trend. We have way more data than you have when in a traditional care delivery.

And we can actually identify patients who would benefit from a medication titration upstream of when they would have a traditional visit and start to make interventions earlier with patients. We just recently had a patient, patient story where the patient was like newly enrolled in the program was alerting, with BP's of like 180 over 105. And within two months, we titrated the patient's meds three times so that we could. And then within two months, the patient was at, at goal. So, in a traditional care delivery model, you're not going to have the patient come in 3 or 4 times in a two-month period. So, we're able to kind of make those small little adjustments with the patient on behalf of their PCP and get them in their control.

Dr. Craig Joseph: And all of that goes back to the electronic health record. So I as the either the PCP or the cardiologist, you're not actually since you and since you've said this clearly, let me re-emphasize, since there are already protocols in place, let's say if this, then your doctors and nurses can do this, you don't need to talk to the primary care doctor or the cardiologist. So, we're going to go up on this medication a little bit and see what the responses and the physician will, you know, be able to follow that along if they're interested just by looking in the air. Did I get that right?

Dr. Eve Cunningham: Correct. We are very sensitive about inbox messages. We already know that clinicians have are completely overburdened by the inbox. In fact, at Providence, when we brought cadence in, we had a pilot. The pilot was really successful. And then we did not have the approval from the clinical leaders at the medical groups to scale beyond that pilot. Until we did an inbox study show that there was no material increase in inbox messages as a result of participating with it. It was a really important point. And, and it's a valid point thing is, is and I think, you know, this, it's a one size fits all right. There is an art for medicine. There is a level of preference. Most of the doctors that we work with don't want to be notified every time the patient has an alert, but there are those you. And then there are some that are just like, don't message me about anything unless the patient gets sent to the Ed, right? I mean, I don't want to know any of it. And then there's everything in between. And then we have to calibrate our ability to accommodate customization and signal to noise, in our workflows with our clinical teams to preferences at the clinician level.

So, I would say that we have some preferences put in place so that there are some doctors who want to be notified every time we make a med titration versus those that are just like, don't call me unless you need me. And what we've been able to demonstrate with our data is that we don't have to escalate. We 98 to 99% of the time, we can take care of what ever needs to happen without bugging the PCP or the cardiologists nephrologists. And so, it's only about 1 or 2% of the time that we're actually escalating something to them. And it's usually something we want to know, like, hey, your patient had a heart rate in the 40s. And we're symptomatic. We send them to the Ed. They had a heart block and got a pacemaker. I mean, that's usually something I want to know.

Dr. Craig Joseph: Yeah, you probably want to know about that. Yeah. Yeah, I mean.

Dr. Eve Cunningham: And then, I mean, how much of a win is that? What would have happened if we hadn't have been there. Right.

Dr. Craig Joseph: I totally see that. And so, I think one of the key differentiators that I'm hearing, from a lot of groups, is this ability to kind of meet the not the physician group, the physician or the clinician, right. Because there are a good number of us that are and this might surprise you that that are anal retentive and not trustworthy, not trusting others. Right. And we've been burned before. And so, we don't want to, you know, outsource some of that stuff. And so, I can totally see, and I might be one of those doctors who would have said, hey, I trust you as far as I can throw you, and I can't throw you very far. So, I want to know everything. But as you prove yourselves to me, a lot of times it's all or nothing. And it's not just all or nothing for me, but it's the group. And so, if I'm in a 20-doctor practice and I'm the, you know, 1 or 2 of the docs who really want to see everything, I'm, I'm either very upset because of my partners, or my partners are very upset at me.

Dr. Eve Cunningham: We don't necessarily message you about everything, but you can see everything any time you want because it's inside the EMR. We do messages inside the actual EMR inside, and we have notes inside the actual native patient chart in the EMR. And then there's also inside the EMR, an app that you can go into while you're in the EMR. That is because the data that comes in it's so much data. So trying to do it look at it in the traditional EMR is not always the most efficient. So we also have an ability to visualize, the data and that article that's coming out, I told you the New England Journal article, it has some screenshots of what that looks like. And it's pretty cool. And it was based on clinician centered design clinicians telling us how they wanted us to organize the information in the data. Now we're constantly iterating on it based on the feedback that we get from the frontline clinicians saying, this is how I want to be communicated with. These are the preferences that I want. These are the things. This is the way I want the data to be organized so they know what's going on with my patients.

Dr. Craig Joseph: I love the idea of kind of taking so, an app and, and embedding it in the EHR so that as far as the physicians are concerned, there's no login or password. It just kind of works.

Dr. Eve Cunningham: There's none of that. It's on the storyboard and epic like a patient says. Like if you're in a patient chart to cadence RPM data, you click on that, and it opens up the visual. A lot of the clinicians use it for pre-charting. Like before the patient comes in they can close it up. But then all of that the notes and everything are still logged in the traditional chart in the encounters section or the notes section. But we organize it in a more cognitively consumable way. In that storyboard section.

Dr. Craig Joseph: Let's talk about those protocols. How different are they if I'm, you know, number two and number 12, you know, customer of yours are those do those differ significantly? I assume you kind of walk in and like, here's what other customers have done and they're successful with is it a ton of work? You have to redo it again or are you starting...?

Dr. Eve Cunningham: The same protocols. There are nuances and there are definitely some health systems that want their special thing, but there are definitely nuances. So, for example, we get a lot of questions about, well, formularies are different, right. So, one Ace inhibitor may be covered, you know, in one health system more often than others. We fall; we follow because we're working inside of their EMR. We are clinicians have access to their EMR. So, when we're putting in a prescription, we're doing it inside the health system EMR. And we're leveraging their formulary for that. So, a lot of the things that they're asked they ask about specifically are things that we can usually accommodate because we are actually, taking some actions from within their EMR instance. But yes, you're right; we do get a lot of requests, from different health systems. And most of what they come up with is fairly reasonable. Usually things that we can accommodate, they're not protocol specific, but their preference specific, like combo drugs versus noncombatant drugs, things like that. But the bottom line is, the protocols are based on the clinical guidelines, you know, pushed out from ATC.

There's not a lot of controversy around the protocols. They're pretty well accepted. What's harder is how do you translate now those protocols to a technology layer to deliver remote care. And that's one of the proprietary aspects of our technology, is that we're translating what's in those clinical protocols. And then we're driving clinical workflows, clinical decisions, remote care delivery at scale through a translation of those, those, protocols. But the one thing that I would say that is really interesting is the and I think you probably know this because, where you work today, the governance and the way they do the governance for approving the protocols, reviewing the protocols, it's very different across every institution. They all have their different ways of doing that. You know, in some places it's like one person reviews it and it's all good.

I wish there was a way that we could do it more efficiently or faster, because it just seems silly that I have to go from like health system to health system to health system to health system to approve it. And I have ideas of ways that we can do that more efficiently. The clinical decision support platform I built at Providence had a whole governance engine in the back end of it that like allowed for like digital governance to occur. Future state. I mean, when we have 50 or 60 partners, we have to think about how we can do it in a more streamlined way. And I think we're thinking about that. It's just change management in the process. And you don't want to also disrupt like ways that they have done this within the you want to respect the ways that they have set things up within the health systems. I would say of Providence, we did a lot of leading by consensus and so governance was quite heavy, quite a process, to get things done. It's a big health system. Seven states, over 10,000 employed clinicians. So, it was challenging, but we navigated our way through there to, to get some things done. And so, we've done that with other health systems as well. But it's really nice when it's very streamlined.

Dr. Craig Joseph: We have run out of time. Doctor Cunningham and I would love to keep going. I would love to talk to you. I think about maybe for an hour on, change management.

Dr. Eve Cunningham: I could write a book on it. I feel like a management ninja.

Dr. Craig Joseph: I feel that you should. And maybe that'll be the next conversation before we plan the next interview, let me end this one. And the way that we typically do, which is by asking you if there's something that's so well designed in your life that it brings you joy whenever you interact with it.

Dr. Eve Cunningham: The things that give me the greatest joy in my life are these three incredible human beings that are designed in the image of myself, my husband, and the legacy of a family that I love and cherish. And those are my three children.

Dr. Craig Joseph: I wasn't sure where you were going, but now I see it's your children.

Dr. Eve Cunningham: It's my children. And they're at this incredible age, 11, 13 and 16, where we are just having so much fun hanging out with them. Like, I just want to hang out with them every weekend because I know they're not going to want to hang out with me for much longer. And so, no machine, software or object will ever compare to the joy of my children.

Dr. Craig Joseph: Well, that is excellent. I will accept this answer. I have rejected answers before, but I will accept your answer. And I think that's great that you've done that. That these creatures, which apparently are your human children, still want to hang out with you because that's something about your parenting. You have a 16-year-old that will talk to you. That's you've clearly done something. Right. And that's another book. First will be the change management book, and then, secondly, it'll be the parenting book. I look forward to that and before. But all of those I can't wait to read the New England Journal, catalyst article that's coming out shortly or probably has come out by the time that this podcast drops. So, congratulations to you on that. And we wish you much success with cadence. I look forward to seeing all the great things that you're doing.

Dr. Eve Cunningham: Thank you. I really appreciated the conversation. It was a lot of fun.