Integrating Digital Health into Surgical Care

Episode Contents

• 0:00 NovaNav Introduction
• 1:02 Guest Introduction: Dr. Alex Itskovitch
• 2:30 Why clinicians must be engaged in technology conversations
• 3:54 Technology solutions for workforce challenges
• 5:44 CMS TEAM: 30-day post-discharge accountability
• 11:04 Pre-op decision-making that impacts outcomes
• 15:45 The role of AI in healthcare today
• 18:08 Surgeon comfort and trust in AI
• 20:28 The future (and present) of virtual hospitals
• 23:24 Managed care payer adoption and incentivizing better outcomes
• 25:37 Episode wrap-up

Key Takeaways

Together, we discuss workforce shortages, perioperative risk, and how digital platforms and AI can help reduce administrative burden, improve readiness before surgery, and enable earlier recognition of post-operative complications. The episode also looks ahead to the role of virtual hospitals, payer incentives, and how better data and communication can improve outcomes for patients while reducing system-wide costs.

Transcript

Welcome to The Surgical Journey, NovaNav's podcast on everything from pre-op to post-op management in the patient's surgical journey. And today, I would like to welcome Dr. Iskovich. Dr.

Iskovich, thank you for being on our second episode of The Surgical Journey. I'm Lisa Miller. I'm the chief strategy officer here at NovaNav, and our goal is to bring in leaders in the field of digital health and AI and really leading the way for us in terms of how we bring in technology into patient care. So, Dr.

Iskovich, welcome. Thank you for being here. Oh, thank you for having me. Great.

So, I just want to kick it off, maybe just like a short little info about you. You know, I'm really looking forward to, you know, kind of talking about how you see digital health and working, you know, with some, with not just startups, but just with companies and how they integrate digital health with patient care. So, maybe a little bit of background on you so people can get a feel for who you are. Sure.

So, I am, I'm a hepatobiliary surgeon in my clinical practice. I'm also the medical director of the Statesford Cancer Center, a cancer center under Atlantic Health in Freehold, New Jersey. I run the full gamut of cancer services in this region and, you know, very excited to be here. I saw an interesting post on LinkedIn where you were talking to startups and companies about how clinicians, you know, physicians need to be part of the process.

And can you just speak to more of that? I know that was a larger discussion, but I think that's a good entry point for us to just talk about a little bit why that's so important. So, you know, a lot of, a lot of startups when they approach healthcare systems, they're approaching it from a tech mindset. And the workflows are actually where, you know, I think the meat and potatoes are when it comes to healthcare management.

And it's very, very important to engage physicians in this particular setting because most of that workflow, if you're augmenting it and the physicians don't have the buy-in, that is where we see a big drop off after the pilot phase in startups. So, I'm really a big believer that physicians need to be engaged and that is really the pathway to success for startups in this field. Yeah, absolutely. I mean, I think sometimes from a startup perspective, we think, you know, we've got great ideas, but then, you know, do they translate into the real world?

And then, like you said, one thing is from pilot, but how do you get the pilot through, you know, making it a day-to-day part of their operations? So, can we speak a little bit about, you know, we do have a workflow shortage, both, you know, whether it's a physician or nursing or even just generally, you know, in a lot of different areas of the hospital. Can you speak to what, you know, you're seeing or what are those kind of conversations you're having in terms of the use of technology and how important that will be now? So, we do have a lot of challenges with workforce and I think everybody nationally is seeing that.

And I think that the technology, you know, will provide a major solution in the future in terms of, and even today, in being able to solve some of those, you know, workforce challenges. A lot of the workflows that we have can be augmented by technology to take out redundancies, to be able to optimize things for both the clinical staff and the administrative staff, and to be able to remove some of the administrative burdens that, you know, actually impair care. You know, what we really want is, we want clinicians to be in front of patients, interacting with them, having, you know, those very kind of human moments, personal moments. And in order to have that, you know, you've got to remove the computer away from the doctor and allow that doctor to have that conversation.

Well, how do you do that? You do that through, you know, through a variety of technologies that give that doctor some of that time back in terms of being able to do data entry and things like that with the electronic medical record. So, that's where I think, you know, a lot of the newer technologies, especially artificial intelligence, will have a big impact going forward. Right.

And, you know, whether it's, you know, teams or the new access model or, you know, just the number of other bundle payments, even from, you know, regular payers, not just CMS, we are seeing the need for that post-op management of the patients, you know, in a more significant way, 30 days or even more. Do you feel like, as a general rule speaking, that we're prepared for that? And how much will technology, you know, be relied on for those 30 days? So, two questions.

Do you think we're prepared, generally speaking, as an industry, not asking you as a, you know, specific area? Yeah. Are we prepared? I mean, we're going to have to be.

Otherwise, you know, all of our healthcare systems are going to be dinged by Medicare and CMS, of course. But I think that the reason that these ideas are coming out of the, you know, Center of Innovation and CMS is because the integration isn't there nationally. I think that there is an incentive structure that's being pushed through in order to facilitate additional communication, additional attention toward the little things post-operatively where, if you're not augmenting that particular situation early, that leads to a devastating outcome. So, early intervention, you know, and there's a lot of quality data, obviously, behind this.

The ability to recognize and rescue a problem is one of really the fundamental tenets of, you know, our understanding of, you know, where quality science is going. And so, if you really think about it, right, if you identify a problem earlier and you are able to fix that problem sooner, that avoids the readmission, that will avoid significant downstream complications, and frankly, that will also reduce costs. So, you know, in this situation, really, there's an alignment both on the clinical side and on the economic side. But that requires a lot of work on the front end to do that.

So, you need technology, but I think you spoke earlier about workflow. So, you're almost having to really have a care redesign or really an understanding now of different pathways depending on, you know, the patient. So, that takes a lot of work to do that. So, is that like, you know, resistance to that or just trying to fill in and figure out where to place it?

Or I think that's, for me, I see a big challenge is kind of doing that preparation work to even get that done. I don't know what you see on the front lines. So, I think that there's a lot of work that needs to be done to integrate into the workflows. I think, you know, there's a lot of great ideas and a lot of really great technology and, you know, some wonderful platforms.

But it's taking that platform and actually putting it into the daily practice and actually making it really effective for the clinicians. That is where the real value gets created because you see a lot of technologies that are being brought in that, you know, kind of if you look at it on the surface seem like a fantastic idea, but then actually don't save time or, you know, or make the administrative process more burdensome. Or in some cases, you would think that they're altering outcomes, but they're not. So, a careful evaluation of the technology and then most importantly, its integration into the workflow is key to making this successful.

Yeah, absolutely. I actually feel like those companies that, and particularly for us at NovoNav, how do we understand the specific workflows or how do we, you know, integrate and work together so that it becomes, you know, part of, you know, like the day-to-day operations, like you said. I don't see the patient as being the resistor. I actually feel like patients, in my opinion, you know, would be happy to have a vehicle, a way to communicate something, you know, and then for them, my mom's 90, my mom uses her phone.

You know, I don't think the technology for the patient's the issue. I agree. I think you're absolutely right. I think that, in fact, I think patients are very comfortable with the use of technology.

I think they're happy to have some way that the process is being registered in an electronic format. They're happy with getting additional information, especially with some of the new AI assistants. They're happy to even communicate and ask questions and understand that that particular platform is endorsed by, you know, the practice and the information, if it's critical, is going to be conveyed to the clinician. So, I think patients are on board.

It's really getting clinicians, administrators, and really all of the alignment that happens in, you know, the complex delivery of care all on the same page to really make it work is really the challenge. Is there anything from, like, a digital pathway perspective that, you know, that you want to speak to? And maybe I'll lead this a little bit. From the pre-op side, is it, how important it is for you as a physician, as a surgeon, to have that readiness for the patient on the pre-op side?

So, you know, when they go through that surgical journey and then they transition out, you know, once they discharge, how important do you think that is? I know it's important, but maybe, what do you look for or what could be very valuable from a technology perspective? So, what I would say is that, you know, and I say this to every patient, I think 80% of an outcome is preoperative decision-making. You know, it's the classic adage, you know, every war is won before it is fought.

And I think that's really the key is making sure that you are looking for the cardiac risk factors and augmenting them, the respiratory risk factors, augmenting them, making sure that they're stopping their blood thinner, making sure that all of those little, little details that if missed could potentially lead to a bad outcome are accounted for. And that is foundational to, you know, good surgery and good outcomes. You know, I say this, you know, to folks, you know, from a technical side, you expect me to do a good job, but I think the differentiator is, you know, or a lot of the differentiation happens at the attention to detail preoperatively that has then an impact postoperatively. So, can we talk a little bit of that?

Because I agree the details do matter. So, is that something that, you know, here at NovoNav, because we are an end-in-end system, right? So, we manage pre-op to post-op. We're able to look at those details.

We're able to customize that for our surgeons. And so, that's also, you know, that's a practice you have and a discipline. Now, we've got to kind of get that universally speaking. I think that might be also a challenge, right, to have kind of build that discipline universally.

So, I don't know what your thoughts are about, you know, getting that mindset or getting that discipline together on the, you know, having hospitals and doctors know that the pre-op side really matters, you know, and I'd like to get your thoughts on that. Sure. So, I would say that, you know, what you want to do is you want to reduce inter-surgeon variability across, you know, a practice and sometimes a healthcare system. You know, some surgeons do it better.

Some surgeons do it worse. Some surgeons do certain things better and other surgeons do other things better. So, what you really want to do is you want to get the best of all worlds and you want to integrate that into a digital platform that helps facilitate that and to make sure that all of the things that are critical to that patient's outcome are being accounted for. And, you know, when we individually as surgeons, when we have, you know, outcomes or we see things clinically in our practice, you know, we're biased to those things.

So, if say that you were in your training and you saw a life-threatening pulmonary embolism happen with a patient, you're going to be much more aware of that pulmonary embolism in your clinical practice than somebody who maybe did not have that experience. But what we know is that pulmonary embolisms do happen and some of them are very serious and everybody should be taking that seriously. So, how do you get that, you know, across the board safety net? Well, you do that in a way where you integrate that digital platform and make sure that every little piece of that, you know, opportunity to augment the risk happens and you do that across the board and you do that with the safety net of a digital technology as opposed to, you know, a surgeon who, you know, is obviously prone to human error or even a practice that despite, you know, checks and balances can be prone to human error.

Right, and that's where AI probably really is so key because AI then would allow, you know, to be that ability to analyze and also be able to, you know, in the future, whether predict, but the use of AI I would also imagine is, you know, also important in the digital technology space. Do you want to speak to a little bit of that, how you're thinking about the use of AI? Yeah, so I think artificial intelligence brings a lot of opportunities to us in, you know, in being able to, first of all, being able to compile, you know, a huge amount of information that clinicians now face every single day and then organize that for us, whether that's through the medical record or in other additional pieces of information that it's obtaining through a variety of other sources, including other records, digital information, images, things like that, and compiling it and allowing us to be able to, you know, make decisions from that. Also, to be able to risk stratify, be able to highlight risk that we may not be seeing or be able to assemble multivariate risk, which is difficult to assess but can be assessed by, you know, something that's looking at, you know, say a million variables in a chart.

And then post-operatively, it's looking for the early warning signs of, you know, things like sepsis, things like wound infections, and so it's able to, you know, utilize digital technology to assess a picture of a wound or is able to look at data on, you know, the walking habits of somebody who's post an orthopedic procedure. So, all of those things are coming. I think they're going to have a dramatic impact on patient outcomes and improve patient outcomes, but at the same time, they have to be implemented in a safe way with, you know, clinician supervision and also, I think, you know, with an eye toward patient safety and ensuring that the technology is properly reporting the things that it's supposed to report. Yeah, so that's an interesting topic, right, in a safe way, right?

So, you bring in a digital technology and you're relying on, let's say post-op, you're relying on, let's say, like a surgical, potentially an infection, right? So, you're relying on whether it's prompts or images, right? So, you would have to really feel comfortable allowing it, you know, the technology to kind of be that first line of, you know, like you said, you know, rescue and recover, be that first line of defense. So, how do you think about that?

Like, what would make you feel good about that? I remember we really thought about that from a safety perspective, a comfort level. That's interesting. So, I think from a surgical comfort level, it's augmenting your current practice and having that technology be there when you're not there.

So, say that I see somebody one week post-operatively, but the technology is now going to that patient and saying, is your wound red? Do you have any pain day one through six? And if something is starting to change over there, maybe you catch that problem one or two days earlier where you would not have intervened otherwise. So, I think that additional information properly assessed and, you know, if it's done correctly, can definitely move the needle on us.

You know, we can't be there at the patient's bedside every single day, but we can use digital technology to help us, you know, get that information sooner. And if there is a problem, get that patient into the office sooner and obviously start antibiotics or, you know, change. Or if, for example, you know, we ask the patient every single day, have you noticed that the width or the circumference of your legs has changed? And suddenly on day four they do.

Well, now you get the patient in, you assess them for a blood clot, and now maybe you've caught that blood clot before it, you know, turns into a pulmonary embolism and becomes life-threatening. So, that's, and by the way, you're also saving a readmission creating, you know, creating all of the things that we want in terms of what is considered a good outcome. Yeah, I love that example, right? Because you're so specific about the measurement and that's something that probably more than likely a family member is doing, right?

So, I think the digital technology is important for the patient, but I actually think that the family members are probably going to be in that also and supporting care very much. On those lines, can you, you know, you and I spoke briefly before about a virtual hospital, and I'd love your thoughts just generally speaking about how you, I mean, having digital technology is going to be so important in having a virtual hospital, obviously, but maybe give us some of your views or vision on that. So, virtual hospital is a reality in some places today, and I think it's really the way of the future. What we know now after, you know, extensive research into ERAS protocols and a variety of other, you know, quality measures is that we don't need to keep patients in the hospital for long periods of time.

For example, in colon resection, you know, we used to keep people in the hospital for a week. Now, we send them home day one, two, three sometimes, you know, depending on whether or not that patient is ready, but we also know that the complications, for example, in colon resection tend to happen day six, seven, eight, nine. So, it really doesn't make sense to keep that patient in the hospital, and the ones that are going to return are going to return irrespective of whether you kept them in the hospital or not. The question is, is if they are having a complication, how do you safely ensure that they return in time before it becomes a real problem, a life-threatening problem?

That's really where the digital technology comes in. That's where the subtle changes that that technology is picking up before they're becoming clinically significant is, you know, where the intervention happens. You tell that patient you need to come to the office, you need to come to the ER, and that's where, you know, where we win. Because if 90 percent of the time that person does not need, you know, that those patients do not need to be in the hospital for that time period, then why are we keeping them in the hospital?

Again, and then for that other 10 percent, well, maybe the technology is the thing that's going to allow us to catch that sooner, and now we're not having any difference in outcome, but we're not occupying those hospital beds. And I think there's tremendous, makes tremendous sense from the hospital side, and I want to ask you a question about the payer in a moment, but if you think about it from the patient and their family side, you know, obviously going to the ER is not ideal for them and their families, and then all the time that they have to take off from work and those who support them. So from an economical perspective, it isn't good for the patients and those who care for them, you know, either, right? They would rather care for them in a home environment unless something urgent came up.

So I think it's, you know, I think the economics are hospital and patient and their families because there's a cost to having to go in, you know, having that kind of outcome versus an outcome at home. So my last question, unless you have anything else to, you know, share, is on the payer side. You know, we talked about clinician adoption and hospital adoption. Do you think that the payer, like a managed care payer adoption is really might be the leader in this area where they might have more of a reason to push that digital?

Absolutely. So, you know, what the payers are ultimately looking for is, you know, a way to be able to, you know, have a savings in aggregate in terms of the overall population of patients. And the way that you do that is you create better outcomes. Well, how do you incentivize better outcomes?

Well, the digital technologies that are being implemented will create better outcomes because they are going to create better communication. They are going to catch problems earlier. They are going to allow us to intervene earlier, which will then reduce, you know, that life threatening complication to maybe something as simple as just taking some antibiotics. And so that also changes the cost curve for the payer.

So everybody's incentives are aligned if you, you know, if you can get this right. And I think that's really the key is that, you know, a lot of, you know, good medicine is good economics. You know, you know, outside prevention is a pound of cure, right? That's what, you know, we were taught as a, you know, as a kid.

And that happens to be true for, I think, all surgical outcomes. If you invest in being able to do as much prevention as possible, you do not need to then handle a lot of very big complications. You can handle small complications and manage them and avoid, you know, bad outcomes for patients. And also, you know, avoid, you know, a lot of discomfort and, you know, other challenges that result, you know, from, you know, difficulties after surgery.

I think that's well said and we'll end here. So I appreciate your time today and having this discussion. This is episode two, so we're pretty early on in the podcast. So hopefully we'll get you back on and, you know, as we kind of continue having these conversations.

So thank you. I'm Lisa Miller with NovaNav. You can learn more about our AI-enabled digital workflows. You know, we make delivering excellent perioperative experiences easy on providers, and I also think easy on payers.

So I welcome you to learn more about us at NovaNav.ai. And thank you, Dr. H. It was a great conversation.