Remote Monitoring, Readmission Reduction, and the Case for Extending Surgical Accountability

Episode Contents

• 0:00 Introduction to NovaNav
• 0:55 Guest Introduction: Dr. Robert Cerfolio
• 2:27 Why Cerfolio Gives Every Patient His Cell Phone Number
• 3:44 Accessibility as a Clinical Standard, Not a Personal Quirk
• 4:52 How Residents Respond and Whether This Model Scales
• 5:34 Leveraging Digital Technology: Telemedicine and Pulse Ox Papers Rejected Before COVID
• 6:37 Innovation Resistance and Hiding Behind the Safety Card
• 7:52 The Three-Month Standardization and Continuous Improvement Cycle
• 9:10 Consumer Wearables in Post-Op Monitoring: Whoop, Apple Watch, and Actionable Data
• 10:09 The Pneumonia Catch: How Remote Metrics Prevented a Potential Death
• 11:43 Care as a Spectrum: Before Admission Through Long After Discharge
• 13:18 Scaling Post-Op Visibility and Where AI Fits
• 14:25 Video Navigation for Surgical Patients: A Practice Started in 1996
• 16:00 Barriers to Scaling Across Education, Technology Access, and Demographics
• 19:44 Accountability, Culture, and Ownership Across Surgical and Medical Teams
• 20:08 The Efficiency Quality Index: Physician-Defined Metrics That Stick
• 22:47 Building the Ideal System-Wide Perioperative Infrastructure
• 23:05 Pre-Op Virtual Home Walkthroughs and Environmental Safety
• 24:19 Personalized Post-Op Goals and Real-Time Metrics at Home
• 25:00 Why Getting Home Faster Produces Better Outcomes
• 26:25 Pre-Op Home Visits, Fall Prevention, and Leading Before the Adverse Event

Key Takeaways

Drawing on decades of surgical and executive leadership experience, Dr. Cerfolio explains why better outcomes depend not only on what happens in the operating room, but on what happens before surgery, after discharge, and across the recovery journey at home. He makes the case that extending surgical accountability beyond the hospital is not simply a patient experience initiative—it is a quality, operational, and financial imperative.

Transcript

Welcome to the Surgical Journey, a podcast about putting patients at the center of surgical care. From preoperative readiness to recovery at home, we talk about the real processes and data that shape outcomes. Each episode features conversations with health system leaders, surgical teams, and technology experts who are changing how patients move through surgery and recovery. At NovoNav, we focus on making surgery easier for patients and their care teams.

That means clearer communication, reducing administrative burden, and smarter use of data. In this series, you'll hear how that work plays out in real clinical environments. Let's get into the conversation with our host, Lisa Miller. Today on the Surgical Journey, I'm sitting down with a surgeon and healthcare executive who has refined what the postoperative experience can look like.

Dr. Robert Cerfolio is a professor of cardiothoracic surgery at NYU Langone Health, where he serves as the chief of clinical thoracic surgery and director of the Lung Cancer Center. He's one of the highest volume thoracic surgeons in the country, performing, I believe, over, it says 1,200 here, but I think it's 1,700 cases. Oh, it's 19,500.

Okay, there you go. Almost 20,000. We're almost at 20,000. But what makes Dr.

Cerfolio, unlike almost any surgeon that we've had here or really anyone I've researched or talked with, is that the executive vice president, vice dean, chief operating officer of NYU, he led an enterprise operation of over $11 billion in the academic health system. And he really understands on the clinical side, working with the patient and the patient experience, and also being the number one robotic thoracic surgeon in the world. And I encourage everybody to look that up. Yeah, that's ChatGPT and Grok talking, not, at least the talking, but I appreciate that accolade from ChatGPT and Grok and other AI platform.

Thank you. Welcome to the podcast. Thank you. My honor to be here with you, Lisa.

Thank you for your time. Yeah. So we'll start off with our first question. And that is, you have been known to give every patient your personal cell phone number.

And really, that thinking, you really wanted that to kind of be part of the culture or just part of, you know, what you demonstrated and talked about when you were COO. So what was that direct line of communication or what has that taught you about patient outcomes that some of the traditional models miss? First of all, thank you for having me on. I'm honored to be here, one.

And two, that was something I did long before I was COO. That's something I did when I was in Alabama. I was in Alabama, Birmingham. That's where my wife and I lived for 21 years.

My wife passed away. She's buried there. My children were born and raised there. It is home.

So when I was in Birmingham, Alabama, I gave every patient my cell phone. I had nothing to do with being COO here. You know, you can be the best surgeon in the world and the patient doesn't know it. They're asleep.

They're paralyzed. And they ain't watching anything that's going on. They can see the outcome. They can see you do it faster than anybody and lose less blood and get more lymph nodes and have a better R0 resection.

We can show that. But they don't know if you really care. And most surgeons care. But we get burnt out answering the same questions.

I've done 20,000 operations. That means I've had that same question over 20, 40,000 times really because the family asks. But the reality is unless you're accessible on a Saturday night or a Sunday morning or a Sunday night or Easter or Christmas or Passover when someone's having a problem, it's hard to make the patient happy. So I found out a long time ago being great in the OR is a small piece of being a great surgeon.

Being a great doctor and caregiver is being accessible. My dad always told me, you know, you might be able, but unless you're available and affable, the three A's, none of it matters. So I'm always available 24-7 for my patients. There's no off call.

They don't call my intern. They don't really talk to my nurse unless I'm in the OR and she's great. But they can text me. I don't like being called.

Don't call me. You better text me. And I'll respond when I can or email. So I just think that's the only way to really offer people a good product is to be available because it's one or two in the morning.

And for them, it's their only time having that operation. You have to remember that every time I go to the OR, I say to my team, for this patient, because we have five today, this is the only one that matters to this patient. Let's get it perfect before we start thinking about the next one. So I've got two follow-up questions and I just thought of it.

So you work with hundreds of residents. Right. How does that translate to your residents? Like, are they like, this is great?

You know, how is that message translated? Well, the resident likes it because they're not getting called by my patients. The patients call me directly. They're calling me, so it's great for them.

Do I think that they're going to go out and scale and do this? No, no. Yeah. Right.

But it's generational a little bit. It's cultural a little bit. And I think a lot of people just want some downtime. To me, I have lots of downtime.

I'm on the golf course Saturday or Sunday or I'm in the gym or I'm swimming. What do I care? That's why I don't like to call. What do I care?

Because I check my phone maybe every minute or two minutes. I answer a text to make a patient feel loved and valued. And more importantly, one out of a hundred actually is having a real problem. The other 99 think they are and we make them all go home with a pulse ox.

I've always leveraged digital technology. I wrote a paper on telemedicine in 2013 and the reviewer rejected it, said, Sirfolio's a bad doctor. He doesn't examine people. Telemedicine's a joke.

It'll never work. I had people coming from other countries and I didn't meet them to the morning of surgery. Better make sure they were surgical candidates with two or three calls before. Check their heart, their lung, their CAT scan, the PET scan, the biopsy, the lymph nodes.

We did all that. The paper got rejected. Everybody told me this wasn't safe and scalable. Six years later, COVID hit and now what happened?

So of course it's better for patients. So is a pulse oximeter, which we wrote a paper on in 2016, how it could help people at home who were anxious and worried that I could say, hey, your saturations are fine. You're well oxygenated. Your heart rate's good.

You took your temperature. You don't need to go to the ER. What you're feeling is everybody has a little low grade fever after lung surgery. That paper got rejected.

And then of course COVID hit and now, so these things that we were doing, people don't like innovation. Innovation is disruptive. It disrupts the entrenched and makes them feel uncomfortable. It moves people's cheese, so to speak.

We all have read the book and no one likes disruptive technology like things that I love to do. Our patients wake up with no chest tube. We take them out. People think I'm crazy.

I just presented an hour before you to a group in Europe and there were 80 surgeons. How many of you are going to go home and take your tubes out before you leave the OR? One hand went up. So I got one person.

I'll take it. Innovation. Yeah. Yeah.

I think it's a whole nother probably podcast on why innovation seems to, people seem to be uncomfortable with it or why it may lag or why, you know, but I see it now with AI and I know we're deviating a little bit, but even as I talk about AI with hospitals and I talk a lot about on the business side, right? I'm not even talking on the clinical side. It is so uncomfortable on the business side to say, well, why not use agentic AI to do, to analyze service line profitability? Like, of course we, we do.

We shouldn't, we do. And the doctors use it and hide behind the safety card. And I read in an editorial, maybe you want, might want to read that. It's called hiding behind the safety card.

But you know, we stand and take an oath and say, we will do no harm, right? We stand and raise our right hand when we get to graduate medical school, then we have eight more years of surgical training. So part of that is cultural. I don't want to do any harm, but I have surgeons say in our M and M meeting, our morbidity and mortality meeting, well, I've been doing it the same way for 28 years.

And then like, then you're a buffoon because if you're doing the same thing today, you did 28 years ago. What industry is successful doing that? I want to get better every day. So we have, but we stand and I, so for three months, we say, this is the best way.

And every three months we challenge ourself. What can we do today to get us better, to give our patients better outcomes? And I know I'm way out and we're way out on that innovative front, but it's what's made us, when you ask chat GPT, who is the world's best robotic thoracic surgeon, because we published the paper with the best results. It's because of that innovation that got us there.

Yeah. Agreed. I agreed. I could probably keep this conversation going more on that.

You a leading, you know, being a COO and bringing innovation in, but I'll save that. Okay. We're doing another time. So the second question I have is around, you know, your patients send you EKG readings.

It's really, you know, continuation on that earlier conversation, right? Right. Readings for their Apple watch. I am a whoop wear.

Hang on. Take a look. Got a whoop and a sleep eight mattress. You can't get better at something if you don't measure it.

That's right. And so I'll talk about, I love whoop and it has really changed a lot of my sleep patterns where I'm thinking, of course, everything I'm doing, I'm measuring and I'm making those micro improvements. And I'll share one story in a moment. But my question around that is, you know, your patients are sending you EKG.

Actually, you could do it on your whoop now, a pulse ox, daily text, their vials. So, you know, how is that this consumer wearable technology reshaping post-surgical monitoring and, you know, the relationship between you and a patient? Yeah. So some people are afraid that this is being monitored by the government or this is radiation.

I can't convince them that it's not happening. So it's not my job as their surgeon, but then I add them to get a pulse ox. If they already have a wearable, it's real easy. I just ask them to send me their whoop data and the HRV is very laudable information and their sleep.

I have them send me that as well because I really know how they're doing then. And I can even say, did you have some alcohol last night, bro? You know, probably you shouldn't. I'll be three days after a lobectomy.

So I get information that they sometimes don't want to share. But so I think, you know, information that is actionable is the kind of information that we want. And it's why I've had the whoop and all three of my boys have had a whoop for at least seven years, six, seven years, very, very long time. And I mentioned the sleep-aid mattress and I get no money from either company for saying this.

I get asked this question all the time. I'm not paid by either one. But I think, you know, if you want to be the best in the world at anything, I want to be a better sleeper. You have to measure.

So for the patients, it allows me to know, you know, in the old days, we used to have maybe one or two percent of our patients get pneumonia. And if you could find it sooner and get them in sooner and treat her, they did well. Now is maybe one in five hundred. But I had one last year and, you know, she sent me her stats and, you know, I get seven or eight of these a day.

And I looked at roll, scrolled up on the screen and it was down seven percentage points. I'm like, do this again. This is probably a misnomer. And then it was I called her.

I FaceTimed her, brought her to the ER. She was getting an early pneumonia. We treated her. She went home two days later.

Fine. In the old days, that's the patient of mine, Robert Sirfolio, that may have died because I wasn't smart enough to measure them at home. I didn't I didn't think about it. I was too myopic.

I was thinking about me and my family and not what could be happening at home with my patients that I could be doing a better job taking care of them after discharge. It was a surgeon. We kind of thought from, you know, admission to discharge or some prehab. And there's some post-hab.

But that was our time. The reality is it's a spectrum of care. We're going to take care of our patients long before we meet them and long after we're done operating on them. I love this story because I was really wanted to ask you a story earlier.

So you gave this really perfect story about how that the data really pinpointed, you know. And I think I think the reason why whoop got so big, I was listening to the CEO talk about what they were actually not doing very well. And I think what happened was it was a golfer who caught I think it was was ready to was it COVID or sick or basically or they were ready. You know, he felt a little off, just a tight, a tad bit, but the whoop picked it up.

Yeah. Yeah. Whoop does that for all of our patients. And it's a it shoots an early warning signal when you're getting a prodrome, when you might be getting sick.

And then you can take some tyro. If it's a virus, you could take a Tamiflu. You could take other types of, you know, antiviral, even bacterial agents that can help limit that course. So it's actionable information.

That's why I really want my boys to keep wearing it. So my next question is, you know, it's obvious what you do with your patients for your patients really works. But it really depends on you, but you make it work. You actually made a good comment before, like, you know, you're they're texting you and you're finding time.

You're not you're there's nothing that is is you're not missing out on anything in life. But how do you think, you know, about scaling this post-op visibility, you know, and you know that, you know, we're we're with NovoNav and we're looking at helping hospitals and doctors scale. Right. So, you know, how do you think of it in terms of really scaling this out?

So so NovoNav gets it. NovoNav is a company or an example of a company that's going to scale this. You need to leverage A.I. You know, I can do it for the three or four hundred people a year I operate on, but I can't do it for three million Americans.

But you all can and your company can and it will. It's why it's going to be, you know, one hundred million dollars, maybe a billion dollar company, which is what it should be, because it has exactly the right processes to scale these things. And so I do think that is what we need to do as a society. And, you know, the other thing is patients have a million questions before surgery, the day after surgery, when they go home.

And I've been making videos. I'll tell you a quick story. I had a medical student meet up when I was in nineteen ninety six in Birmingham, Alabama, my first month as an attending my patients didn't know where to go. So we had, you know, those giant cameras you put on your shoulder that would be.

So I had a medical. I was seeing a patient in medical since I live near you. I said, would you do me a favor? Do you mind bringing him to work the day of surgery?

I'm going to have the medical student videotape this show you where to park, where to go, what it looks like walking in. We made a video. I sent it to our administration. They actually loved it.

Thank God, because now I think about I would get and get sued to have a medical student hop in a patient's car. But we made this for patients in the university a year later. Roll it. I gave it to all my patients just to reduce distress in the morning of surgery.

Where do you go? Where do you park? How do you get in the hospital? What does it look like?

Such a simple formula. That was July of nineteen ninety six. And then I made videos of what happens on your way to the OR. A year later in ninety eight, we made videos, what it looks like post-op.

And in nineteen ninety nine, I had patients say what it looks like each day after surgery. And, you know, that was what, 30 years ago. And I ain't no genius. Let's be honest.

But people, those videos we played again and again in our waiting room when people were waiting. Now we send them out, of course, digitally. That's what you all are going to do. But you're going to scale it.

I just did it for nineteen thousand five hundred people I've operated on. We do do it here at NYU in a very good way because we push this when I was CEO and others have as well. We want to give video, especially in orthopedics, of what exercises to do, what the wound looks like, when you can bathe. All these things are questions that every patient has.

And we think we tell them when we give them these sheets of information. Everybody throws those out. Nobody reads that nonsense. But an 83 year old may be may not be able to play a video on an app either, or they may not have even Wi-Fi at home.

So we have to also be able to take care of the indigent or the people who maybe aren't as sophisticated or educated as well. So there's multiple barriers here to patients that we have to find a way to overcome to scale this to people of all different races, genders, level of education and level of sophistication. Yeah, that's fantastic. So two quick follow ups.

I think I I think years ago I was watching my CBS News or some news. I think you were on the news about you taking, you know, doing the videos of patients. I believe that was you on the news, I'm from New York, New Jersey area. But prior to what I'm doing now, I actually I was a founder and the CEO of a company called Via Healthcare.

And it's it's I exited. But one of the things we used to do or I used to do peri-op assessments, but I would start at four thirty five a.m. and I actually do the assessment. It wasn't I didn't have to do it, but I would start it in the it where the patients came in in the parking lot and I wanted to see what they saw.

So great. And I would I would I would say to the CEO, usually in the CFO, did you know that everything was dark in the morning when they got in? If it were that so scary, they pulled up or the main entrance was locked and they had to go through the E.R. and just to just following the path, you know.

And so I always wanted to think about not just that peri-op experience, but what what it was for the patient experience from the moment they got to the hospital. Exactly, exactly. Well, most of them are so stressed, they're hungry, they're dehydrated, they didn't sleep, they're stressed, they don't know where they're going. So just to be able to find the hospital and then when they get there, all these hospitals are gigantic, you know, hundred acre facilities.

The signage isn't great. Where do I go? Where do I park? If you take an Uber or cab, where do I get dropped off?

We wanted to eliminate all of that for my patients way back in my first meeting. It's amazing. It's amazing. I just I love that.

I think my point is is like I hand wrote it. But the fact that you actually videotaped it, it's like every hospital should be doing that. So I just love it. I want to congratulate that medical student who now is a very good thoracic surgeon and some many years later.

But for having the fortitude, I'm like, I'd like to video the medical student and say, listen, I live right next to the guy. I'll just come in with him. I said, really? He said, yeah.

I said, don't show. He showed everybody's face. He showed everybody's face. And you know what?

UAB, University of Alabama, to their credit, was OK with that. And we use that for thousands of my patients and others to help reduce their stress. Yeah. Highest word of power.

Yeah, it's amazing. So two more questions for you. That's weird. One is you have proven that staying connected to patients after discharge improves outcomes.

So can you talk a little bit about culture? Right. So what kind of you know, how does that culture work across the health care system in terms of ownership? You know, whether it be, you know, so every surgeon and every care team embraces it.

I say everybody, everybody may not. But just how do you really talk through that, particularly now? And I look with CMS teams and so many other things. So one of the big problems are, you know, it's surgeons.

It's easy for surgeons. They get that. They own the patient, the surgery, and they take care of them. Although even trauma surgeons now, sometimes even in the middle of the case, I hear there's tag teaming and surgeons changing in the middle because of timing out something that actually would obviously never happen to someone my age.

But that is part of the culture. But there has to be accountability. So I think if you're a surgeon, it's pretty easy because there's a start time and end time at discharge and that surgeon owns it. But if you're say an internist or a hospitalist and you work only a couple of days a week and you admit the patient but you don't see him for a few days, who's in charge of the discharge and the quality care?

So we had to ascribe accountability to some of our medical teams that had more disjointed care than a surgical team. So initially we did it to the admitting doctor and they didn't like that. Fine. We made it to discharge.

But somebody has to be responsible why that patient is there two days too long, why that patient didn't know what medicines to take when they went home. It is accountability. And then publicly display their report cards or their scores on these issues that we very carefully measured. And I created a metric called the EQI, the Efficiency Quality Index.

That's a whole nother podcast. At least I just spoke in Italy and in another country, Singapore, about how the Efficiency Quality Index is the key index that gives doctors a score that they believe. It measures things the doctors tell us we should measure as administrators. We give them their value so they can make sure they're accurate so they can't say it's inaccurate.

So when you give a doctor a scorecard, they always say, hey, you administrators, you measured the wrong things and my data is wrong. With an EQI, I say to the doctor, you told me what to measure. And the data can't be wrong because you had a month to vet it. So now there's nowhere to hide.

So the EQI really gets the doctor's attention because it measures things that matter and measures accurate data. And then we show them how they're doing compared to their peers and it inspires them to get better. So I think, you know, measuring things that matter and measuring them accurately or reporting them transparently, but also knowing that, you know, people fail. We all fail.

So we're going to be super tough on standards, but we're going to be a on people because people fail. And if you're really trying hard, we're not going to give you the business. But if you're not trying hard, you're out. You can't work here for us.

Yeah, that's great. I would like to learn more about the EQI. Yeah, that's great. Yeah.

I'd love to talk to you about it. I have several papers you can read. They're all published. Yeah, I will look them up.

So if you could build the ideal system-wide infrastructure to standardize the experience that you deliver for your own patients from pre-op, FaceTime to post-op text, what would that look like? You've kind of talked about it throughout this podcast, so it's not anything new. So maybe just a couple more pieces. I mean, you've really.

I like the idea of going into their home pre-op. I still do that. I'm one of the few doctors who does it. I'll tell you why.

If you look at my data from about 12 years ago, I had a few people slip in the shower post-op. One didn't break her hip and hurt her hip. I had someone hooked her elbow getting on and off the commode. That's on me.

If I did the operation better with less pain, it wouldn't happen. And if I went into their home and today you have a tub you have to climb over to take a shower, you're 83 on crutches, don't think so. We're going to get you to a home where you don't have to climb over. Do you have an anti-slip mat in the bathtub?

I look at that. So I do FaceTimes out of people pre-op and say, show me your stairs, show me your bathroom. You're going to be using the commode and the sink. I shower.

I've been doing that for only 10 years. I should have been doing it for 30 years. I wasn't smart enough. So we have to do that.

Look at the home they go home to and then who's taking care of them. Many of our elderly people have a spouse that's in worse shape than them. And it doesn't make sense to think that they're going to be taken care of by that. So we have to have a son or a daughter or a friend come in.

That's part of it. During the hospital, we're great because we have them, but we only have them for 20 hours. They go home in less than that in our institution. And then when they go home, we probably should really do a daily FaceTime with them.

I don't do that. I only do that if their metrics are down or if they go home with a chest tube or something else. And then I think very precise, personalized post-op care. For instance, I just saw an 83-year old.

She walks three miles a day. I told her the day after surgery, I want her walking a mile. The patient I saw after is in a wheelchair. So he's not going to walk at all.

So you have to have personalized post-operative goals for that patient for each day. And I think if we do that along with real-time metrics, HRVs, heart rate, temperature, saturations, we'll give people best care. And here's the good part. The cost of the care goes down as the quality goes up.

No one gets readmitted. Our readmission rate is one of the lowest in the country. We have the lowest length of stay in the country. We have the lowest chest tube time in the country because most people don't even have a chest tube.

All those things are measurable. They make less pain. People do better. And then there's more beds to take care of people who need them.

There are way too many people in the hospital today having breakfast that don't need to be in the hospital. For the people listening, the hospitals are bad. You don't want to spend that. I have people go, oh doctor, can't I spend two nights in the hospital?

No. You get confused. You're on a bad bed. You get bad food.

You could get the wrong medicine. You could get COVID. You can get C. diff.

You get confusion. You can fall. You don't walk. And if you're having pain, you can't get your pain medicine because it's three hours and 58 minutes and the nurse won't give it to you until it's four hours.

So much better to go home sooner is better. And I think that's the big message. That was fantastic. And one thing I want to share, I actually read that you did daily, I'm sorry, you did pre-op home visits.

And I read it and I'm like, oh, I'm not going to mention it because he's going to tell me he doesn't do it anymore. How can he do it? No, he's still doing it. No, I know.

I read it that you do this and how you check the bars in the bathroom. I thought, this is amazing, but I'm sure he doesn't do it. I don't want to bring it up in the podcast. But I want to tell you, if I was a real leader, I would have done it before someone slipped and hurt her hip.

She could have broken her hip. Thank God she didn't. And the other patient who hurt her elbow slipping off the commode. If I was real leader, I would have thought about having them put a bar by their commode before surgery, which a lot of people do now.

Or using, if they can't hammer up the stairs, we'll use a bathroom downstairs. Or if that bathroom is one of those raised showers and they got to go to their son or daughter's house for a few days. And the son always says to me, thanks a lot, doc. It's just two days, bro.

She took care of you for 30 years. Now it's your turn to pay back. It's just two or three days. A hundred percent.

This has been just an amazing podcast. Thank you so much, Dr. Sperlio. Thank you for your time and your insights.

It's a lot of learnings. Thank you, Lisa. God bless you. And thanks for all you do for so many patients.

Thank you. All right. Bye-bye. Thanks for listening to The Surgical Journey.

Join us next time as we continue examining smarter, more connected approaches to perioperative care.