92Y City of Tomorrow 2020: Making Hospitals Work Better
ICRAVE founder, Lionel Ohayon spoke on a panel at 92Y’s City of Tomorrow in October alongside Niyum Gandhi, EVP and Chief Population Health Officer of the Mount Sinai Health System and Jim Crispino, Healthcare Leader and Principal at Gensler. The panel was moderated by Kirsten Waltz. Click to watch the full conversation, or read the transcript below.
Kirsten Waltz (00:00):
I think to start off this morning, our topic for this morning is making hospitals work better. And I'd love to start off the conversation. We're going to have three questions this morning with each of the panelists speaking on these three questions. The first question will be, how is the pandemic reshaping patient care within the hospital and the community at large? Niyum, I was hoping you could start out with this question.
Niyum Gandhi (00:31):
Sure. You know, it's from the perspective of a health system, you know, caring for patients who will have COVID. I think it's been ... It's varied through the different phases of the pandemic. Obviously, initially when the case loads were going up in the first couple of geographies back in March and April it was re-purposing all of healthcare to take care of one disease. But now as we've come out kind of on the other side of that, there are some lasting impact to how it's shaping patient care. Certainly within the facility, the idea of kind of having flex capacity is something we previously did not really plan for. We had emergency preparedness. But you know, being able to surge up to capacity rapidly, that's different. Thinking about cohorting patients is certainly different.
Niyum Gandhi (01:26):
And then, you know, I think, especially thinking about the fact that there are many, especially with a disease like COVID where there's a lot of asymptomatic spread, there's a lot of transmission during the incubation period, the idea that any patient who's there for something else may also be COVID positive. And so social distancing in the waiting rooms, temperature checks before you come in, it's a completely different set of operations. I think often people forget that healthcare delivery is an operations business. And so the same way that, you know, if you're running a manufacturing facility, you have to rework every aspect of your operational workflow to accommodate the fact that there may be 1%, 2%, 3% of the population who are carrying a communicable disease here that has impact on the community at large, we have to do the same thing in healthcare as well.
Kirsten Waltz (02:20):
Excellent. Thank you. Lionel. Do you want to add to that?
Lionel Ohayon (02:25):
Yeah, I think one of the interesting impacts that we're seeing is, is the notion of having caregivers in hospitals and the impact that we're learning that actually has on the operations of the hospitals. As you're seeing these hospitals actually evolve and not have families coming for patients, it's streamlined the process of actually delivering care. And I think that that's going to become an important conversation as we move forward, looking at hospitals about how are these hospitals actually working? We know that we're dealing with anxiety of patients, we're also dealing with anxiety of those people who bring them.
Lionel Ohayon (03:00):
You know, have we really designed hospitals to allow for that to be the most streamlined process that we can? And if it changes, how will it change this operation system that we're discussing right now, which is delivering healthcare?
Kirsten Waltz (03:18):
Excellent. James. You're on mute, James. If you could ...
Jim Crispino (03:26):
Sorry about that. I had myself muted while Lionel and Niyum were talking. So from our perspective, the problem's got two parts. It's kind of a population health problem. And then it's a system design problem, right? And so our population health models, I think, have to become more attuned to what's going on in their communities. And so our sort of means of detection can become more sophisticated, but also be founded on an understanding of what the status in the communities are. So, you know, traditionally these models would take into consideration the demographics, age distribution, disease incident rates, and those different age cohorts and how services can be distributed within the communities to address these issues. I think other factors that need to now play into this have to do with social determinants of health and status. And frankly, I think you're going to see the emergence of new providers into healthcare to specifically address this situation because the financial incentives historically have not supported large portions of the population that really need a regular engagement with healthcare providers.
Jim Crispino (04:41):
I think the second part of this, what we've learned in the hospitals themselves, is that it's devastating to the provider and to the community to basically shut down the entire system to care for a single disease. Everything else came to a grinding halt. And the pandemic really exposed these weaknesses to us. And so we now need to think about ways that we can maintain sort of normal operations and the provision of care while we're addressing these major events like a pandemic or mass casualty or whatever it may be, all of that needs to factor into our planning. And it places a real premium on flexibility. We're looking at sort of multi-track systems within the hospital that could function for one set of patients under normal circumstances, but be converted, say in a pandemic, to care for those people affected by the pandemic and keep them on a separate track while still maintaining the rest of hospital operations. Now, you have to think about that continuum all the way through the hospital. I mean, COVID exposed weaknesses in the critical care chain, in our emergency departments, in our ICU beds, and variable acuity beds and so on. But I think from a planning and design perspective, we really have to look at it systematically.
Niyum Gandhi (06:10):
You know, Kirsten, just one thing I'd add to that to James' the point. I think that point on flexibility is absolutely paramount. And I'm just thinking about some of the decisions we're making on the heels of this of how do you space flexibly because we don't necessarily ... Healthcare isn't financed in a way to necessarily support a bunch of standby capacity. And so we're looking at things down in the weeds. And I shared with Kirsten earlier this week, we had a proposal come in from one of our hospitals around. They were doing a renovation of an OB floor for labor and delivery. And there's a question about, okay, for these 14 rooms, should we spend a little bit of extra money to make them able to be converted to negative pressure rooms? Which the idea of having ... Negative for those who don't know [inaudible 00:06:58] negative pressure rooms help contain the spread of infectious disease. The idea of having negative pressure rooms in a labor and delivery unit is nonsensical. But you know, in a period where we had 2,300 COVID positive inpatients in our hospital just six months ago, everybody's thinking, "Okay, a negative pressure room is a premium commodity if I can create that." And so it's really causing us to think differently about that flex capacity in a way that we've really never had to before.
Lionel Ohayon (07:31):
Yeah. I guess we're all super interested in this topic because I could see everyone's heads nodding about it. You know, I was talking earlier this week about it. You know, for me, I actually think it's an expansive, massive moment in time question about the country and how we manage something that could kill 200,000 people. Right? And the impact of that as sort of a visual into our national defense and how we treat these things and not burden the hospitals, right? The hospitals can't sustain that kind of impact. And this might just be the tip of an iceberg. There could be something a lot worse. So is there a way that we start to reimagine how we spend defense budgeting on something like a pandemic across the country, like an Eisenhower system and say, "This is what we need to do. And we need to be prepared. And we need to build an army of citizens who have a role and understand what their role is in the event that something like that comes along." And that's big thinking.
Lionel Ohayon (08:29):
And, you know, I think that it'll be really interesting to see if we have the courage to get there. But I really think that any scenario ... It's great. By the way, I think it's amazing. We should do that with the OB rooms. But the scale of what we're talking about, you could see how these things just bang into each other. That's like putting a bandaid on a massive problem. And I think we have to do that, but we also have to figure this thing out. And it could be really fundamentally impactful on the health of our cities and the health of all people in the cities because you can create a whole community center that does something when it's not a pandemic and is designed to take that on in the event that something happens. It might even pull some of the things out of hospitals that really don't need to be there.
Jim Crispino (09:13):
Right. I think one of the things that it really has exposed, just to pick up on your point Lionel, is that human health is an urban planning problem, as much as it is anything else. One of the things that I find interesting is that a lot of our academic medical center clients were in the process of rethinking their own roles in their communities when the pandemic hit. So beyond the provision of care, dealing with social determinants, trying to figure out how to deliver, let's call it low acuity care on a cost effective basis so there's engagement with the entire community. And we've seen academic centers around the country looking at developing housing, where there are housing shortages or a lack of affordable housing, developing healthy alternatives for food and for our everyday wellbeing, you know, in the course of their own sort of development.
Jim Crispino (10:10):
And this is a real sea change in the way of thinking of these institutions whose mission historically has been care teaching and research, right? Care teaching and research is what they did. That was the focus. How to integrate those things and bringing them together was a big part of the conversation. But I think what they've realized is that the social housing stress, housing insecurity, food deserts and so on have a huge impact on how the health system is used. And for a lot of healthcare providers, you know, the emergency department was the primary care site for big chunks of their communities. And it's really unnecessary for about 30% or 40% of the people who show up in our emergency departments to actually be in our emergency departments. And only 20% to 25% of those are even admitted to the hospital.
Jim Crispino (11:07):
So the reason why we need to rethink our population health models is so that we can inform the redistribution of care and services in our communities. But along with that comes the creation of awareness in those communities, that people can go to these places that are in their neighborhoods and know that they're safe, know that the services there are comprehensive, and if they need higher levels of care, they're available to them within the system. That your only alternative is not the emergency department. So there's a communication plan I think that goes along with this rethinking of how we distribute services.
Lionel Ohayon (11:52):
100%.
Kirsten Waltz (11:53):
Excellent. Well, I think that ties in with the next question here is, how has the pandemic and the experience and expectation changed for the patient family and the caregiver? And I'm going to add also, we've talked about flexibility a lot the first couple of minutes. How can technology be leveraged during this transformation and the experience as part of that? If you could speak with that? Niyum, do you want to go ahead and start with that?
Niyum Gandhi (12:19):
Yeah. You know, I think it's ... The pandemic probably accelerated a bunch of things we already knew around this. And so patients, family members, they value flexibility. And our strategy around this has been to give people kind of an omni-channel experience, right? They can interact with us however they want to. If they want to be in-person, they can be in-person. If it's virtual, telemedicine, you know, all of that. It has been shocking to me. I mean, we had telemedicine rolled out across our entire system, almost all of our physicians well before the pandemic. In February, right before COVID kind of hit New York, we did 0.5% of our ambulatory visits via telemedicine. In March and April, we did about 55% of them via telemedicine. And the total volume hadn't dropped tremendously. It dropped a little bit. We were doing more per day during March and April telemedicine visits than we did per year in 2019.
Niyum Gandhi (13:21):
And all the technology was there. All the reimbursement was the same, right? And so people often say, "Oh, the technology's hard." It's not. It's easy. People say the reimbursement's hard. The reimbursement's hard, but it's possible, right? Even before the pandemic. The funny thing was the literally thousands of physicians that we had who said, "My patients won't want telehealth," who were then, you know, cranking out 15 telehealth visits a day, right. Or the hundreds of thousands of patients who actually told us, who voted with their feet. They were like, "Yeah, I know you have this telehealth thing, but I like coming in-person." Well, when you can't come in person, you know, you use it. And guess what? They liked it. They liked it. And they're using it more. And we redeployed a bunch of our assets towards other digital engagement methodologies. We launched a text to chat function that people love. I think the demand around digital and technology, people are getting it now.
Niyum Gandhi (14:16):
And they use it in every other aspect of their life. I mean, when you book a plane ticket, you don't call up to do that anymore. When's the last time you called the travel agent? I book a flight every time I book it on the app in 30 seconds. Right? And we're all used to that. And healthcare was behind and it was behind for a whole bunch of reasons that could probably take three hours for us to all pine on here. But the pandemic showed us that we could accelerate there. Just like, as James was saying, it showed us that we could accelerate on population health, that we could get out into the community more rapidly. And so I think that's interesting, certainly there. The one thing I would just throw out though that it also reveals, and especially because James talked about the social determinants of health here, you know, health equity is really important. And there's been a lot of work in the traditional healthcare delivery system to enhance equity.
Niyum Gandhi (15:08):
When we start thinking about leveraging digital more aggressively, the point of the digital divide becomes really in your face. Right? And so it's easy to say, "Sure. During the stay at home order, we have telemedicine." What if you don't have reliable broadband? What if you have a pay as you go mobile data plan and you can't use it? And our largest hospital sits right at the intersection of East Harlem and the Upper East Side. There are no two adjacent zip codes besides 10128 and 10129, right? Where the 92 Y is located. You know, no two adjacent zip codes in the country with a higher median and income disparity. And we serve those two communities. And it is noticeable. And finding that we actually need to ... It just means we need to invest differently. And more, and in a different way through partnerships with organizations like Silicon Harlem to identify broadband dead spots and invest there to ensure that as patient and family expectations change, we're able to meet all of our patients there, not just some of them.
Niyum Gandhi (16:10):
And so that's work ahead and it's work worth doing. And it will be hard work. And we'll all do it. But the pandemic shined a light on the fact that digital is not necessarily the great equalizer. It can actually be a divider also. And so we need to be ... We just need to be cognizant of that.
Jim Crispino (16:28):
That's a really important point, right? I mean, Sophocles said that, "Nothing vast comes to mortals without a curse." You need to understand both what the upside and how that can be leveraged on behalf of everybody, and what the downside is and how that can be addressed in the communities. You know, what kind of role a provider can play in addressing what some of those disparities might be. So it wouldn't surprise me at all if we see some of the providers that we've been talking about, who have been thinking about housing insecurity and food deserts and other social determinants that, you know, broadband becomes a part of the social determinant conversation, and there's an investment there in making sure that there's robust engagement with everybody in the community. And it's going to be critically important going forward because the hospitals themselves are going to be increasingly digital.
Jim Crispino (17:29):
And this whole notion of the digital hospital has been kicking around for a little while. And I think the pandemic has only accelerated that kind of development. The only other thing I would add is that an important aspect of this is kind of restoring trust in the system. The healthcare providers have to make the people that they serve in their communities aware that they've taken steps to address their safety when they have to come to the hospital. There's a lot we can push out into our communities. There's a lot we can do digitally. But if you need an MRI, or if you need a surgical procedure, or you need to stay overnight, you need to come to the hospital. And so restoring trust in the system and creating awareness that as healthcare providers and people who are concerned with human health generally have done everything possible to address their safety when there's physical engagement, not just digital engagement, but physical engagement with the system is also going to be an important aspect of this.
Lionel Ohayon (18:34):
You know, it's interesting talking about the digital hospital. We just finished the hospital for Sloan Kettering. And the RTLS technology that is implemented in the hospital, we really looked at that as an opportunity of empowerment, right? As an opportunity to create an experience for patients that they may not otherwise get. So by having that technology on the patients, which is basically an RFID badge that you know where everybody is, we untethered people to a clinic door, right? Because everyone goes to a hospital. We start cutting through all the steps, all the procedural steps, and reinventing that interaction that you have. And in a hospital where you're going several times a week for potentially years, for long stays if you're doing chemo or infusion or a radiation treatment, and your moods can change as you're going through there, having technology as part of the experience, aside from just kind of the efficiency that it potentially allows.
Lionel Ohayon (19:37):
What we looked at was how can we make this hospital do more for the patients so that they can be more empowered to be in a positive space so that they have a better chance of having a positive experience in the hospital? And so some of the things that technology are starting to show us that we can do is number one, get rid of waiting rooms, right? Which is a necessary evil because of how it all works. But if you de-tethered me from a clinic door, now I can start to say, "Well, what should I do with all these waiting rooms, which are stacked 17 floors tall, and actually program them to be positive engagements for people so that they're doing something," right? And their mental connection to going to the hospital is about actually inspiring them into something positive, learning a language, writing a book, using Photoshop, going to a class, learning macrobiotic cooking, whatever that programming can be.
Lionel Ohayon (20:30):
And so I see how that's like we're seeing the seed of that happening, giving people choice. Right? And I think that's what digital at its best can do both in the hospital and outside of it. It's like give people choice, give people control, right? And allow them to sort of not have to be victimized because they're sick. Right. You're sick. We can get through this. And it could be a positive experience on so many levels and inspire other people as they're coming through it. So I think that the digital question is really important. I think that you guys are 100% right. This is a massive accelerator of the telehealth, like let's just push through this and get to that level. And then let's see what that does. What does it do by taking all that traffic out of the hospitals? What now can we do in there? And what does it do for people to sort of free them up to do other things? So it's a good time right now for hospitals to invest into new ideas, into new technologies, I think.
Jim Crispino (21:24):
It actually is. I agree with you completely.
Kirsten Waltz (21:29):
Excellent. Well, I'm going to round out this last question. And, you know, how do we think the pandemic is reshaping the physical space? And is that physical space now going to be within the hospitals and clinics? Do we see it expanding within the communities? You know, how do we see that piece moving forward? Lionel, do you want to kick us off for that one?
Lionel Ohayon (21:49):
I mean, I think we don't know. I think it's like how courageous do we want to be? You know, how big of a sort of revolution or evolution do we want to have? When the dust settles, I think a lot of the hospital organizations are going to say, "Why is this falling on us? You know, this is a bigger problem than we can handle. And we need everyone to sort of roll up their sleeves and figure it out." And to the point about urban planning and understanding what our cities look like, I think that's absolutely the truth. And it's very hard for me to posit right now where that goes. And the President of the United States just got COVID-19 and what impact that has on the conversation. This is a broad conversation about how serious something like this actually is.
Lionel Ohayon (22:37):
So I think that ... I hope that conversation becomes a movement. A movement for change, that we really see the idea of how our cities work, our responsibility as individuals, for other people in our communities not to get sick and take that seriously, and then build healthy cities. And I think it's ... You know, you and I were talking about the biggest technology to get us through this is washing your hands and wearing a mask, right? So if the bar's low, if we can get that solved-
Jim Crispino (23:10):
It's not rocket science.
Lionel Ohayon (23:13):
It's not huge tech. We don't need Elon Musk for that part of it. So, you know, I think it could be a really amazing conversation for where we go forward.
Kirsten Waltz (23:24):
Excellent. [inaudible 00:23:26] Do you want to add to that?
Niyum Gandhi (23:29):
Yeah, I think that ... The only thing I'd add, and that's spot on and I'd be interested actually in Lionel and James' perspectives on this. They're more experts on this than I am. But I do, you know ... And maybe I'm a little bit colored by being in New York City for this ... There is a question about where the physical space is needed from kind of an urban planning and geographic standpoint. And so I just look at some of our hospitals that are further away from the core of the city have recovered more quickly from kind of a patient flow standpoint than the ones in the heart of the city. And there was historically ... And we were already moving away from this in healthcare, but historically there was a come to the center for the high acuity care. Right?And it's just kind of how, especially on the East coast and on the West coast, how cities work as it related to healthcare. The country has 2.3 hospital beds per 1,000 people. You know, New York City has 2.8. Manhattan has six.
Niyum Gandhi (24:35):
Why? Right? And it's like, Manhattan has six beds per 1,000 people because it's a third most populous borough. Not the most populous borough. And people from Brooklyn and Queens utilize in Manhattan. And, you know, people from Long Island utilize in Manhattan. And so that trend was already changing, right? There are great, quality institutions further out the side of the city, and more ambulatory surgery centers, and more community practices. But there's a question of, as people ... I live and work in Manhattan, as I look at ... And I went to work throughout the entire pandemic ... In March and April, the streets were empty. You've never seen a Manhattan with less traffic than this. And now the traffic is back, but the streets are still largely empty.
Niyum Gandhi (25:20):
You know, I talked to people in other industries, they work from home two, three days a week. Even if they are in the office a couple of days, they're moving, they're shrinking the space that they're taking overall. Well, this idea of, "Well, do I want a doctor close to home or a doctor close to work?" That discussion starts changing if home is work, right? Or if home is work at least half the time. Even in a post-vaccine, many years post-pandemic world, that discussion changes. Well then, if my doctor is close to home, maybe the other things should be close to home. Maybe I need the specialist close to home. Maybe I want to get the surgery close to home. And you know, that was always a discussion. But when you take work out of the picture as a different location, you might be thinking about utilization patterns differently.
Niyum Gandhi (26:07):
And these are things that hospitals need to be thinking about 10, 20, 30 years in advance. I mean, you don't go just build a new hospital every other week because you found a better street corner to put it on. And so I think there's something there that is yet to be seen. As Lionel said, we don't know yet. But I'd really be interested. You know, you guys are more expert on this than I am. I'd be interested in your thoughts on what's happening to the urban center. And what are the implications for healthcare?
Kirsten Waltz (26:39):
Yeah. James, why do you round us out for the last three minutes here? That would be great.
Jim Crispino (26:45):
Thank you, Kirsten. And thank you for teeing me up here, Niyum. You make a great point about the distribution of services. You know, the borough of Brooklyn has over two and a half million people in it and one academic medical center. The city of Philadelphia has about 1.8 million people and has five academic medical centers. So it's interesting how the historical economic forces have aggregated health services in a way that doesn't necessarily respond directly to the urban and communal needs for those services, right? Distribution of those services historically has not been purely based on community need, right? As it probably should be. The other thing I would add is that the provision of healthcare has also been largely a risk averse industry. And I've had more than one CEO or COO of a health system tell me that they're happy to be second with a new technology or a new operational model.
Jim Crispino (27:52):
You know, there are very few, there's like half a dozen in the US who want to be first, who are really looking for that innovation. But they're a small slice of the industry. Most of the industry is looking to those leaders as kind of the test cases for new ideas, new technologies, new service distributions. So I think using population health models that are informed in the ways that we've been discussing really can go a long way to solving some of these problems relative to how services are distributed and the kinds of spaces we need do that because we are, at the same time, deconstructing the hospital. There's a lot that's being done at the hospital that really doesn't need to be there. I think the only one more thing I'd like to add is we were looking at doing things to improve the patient experience before COVID hit.
Jim Crispino (28:48):
And some of those things included the elimination of waiting rooms, making the medical staff workspace immediately adjacent to the exam and consultation and procedure spaces so that we were both making better use of medical staff time, while at the same time making the access and use way-finding amenities, and so on, easier and better for patients and their families who were coming to the medical centers. Right? So we've done half a dozen projects where there's really no waiting space at all. And we've turned that space over for clinical treatment space, or for medical staff workspace, or for amenities spaces for patients and their families.
Jim Crispino (29:34):
And I think that kind of rethinking has programmatic implications for how we develop our service models when we're contemplating new models for care. And what I'm hoping is that those risk averse folks, and there are lots of them in our industry, will see this opportunity. They will see that the pandemic and exposing the weaknesses provides an opportunity for innovation. And they see that it's actually a greater risk to not innovate under these circumstances than it is to sit back, and wait, and see what somebody else does. There's a certain clarity that comes with this kind of global issue, right, that can focus people's attention on what needs to be done and the ways that they can do it.
Kirsten Waltz (30:28):
Excellent. Thank you all very much. This concludes our panel discussion. And I look forward to talking further about it outside the realms of the summit. So thank you very much. And that concludes our panel.
Jim Crispino (30:46):
Thanks very much, Kirsten.
Lionel Ohayon (30:46):
Thank you.
Niyum Gandhi (30:46):
Thank you. Take care.