Advancing Healthcare Systems With Technology-Driven Behavioral Change Strategies with Douglas Bruce

[Music] good afternoon friends David Wright here and I'm your host of the disruptive innovators champions of digital business podcast and this morning I am lucky enough to be joined by Dr Doug Bruce Doug how are you my friend going well good morning yeah great to have you um so Doug Dr Bruce for for our listeners who who may not be familiar with you or your body of work can you just tell our listeners a little bit about you know who you are where you are today so I trained in medicine at Parkland Memorial Hospital in Dallas in the 90s during the AIDS epidemic and that actually really got me interested in groups U that were marginalized that didn't really have access to the care that they need lots of things happened in the AIDS epidemic and part of my way of processing some of that was I went to graduate school I started thinking I might be interested in biomedical ethics and particularly the rights of marginalized groups like substance users and the right that we should they have to get excellent care um and in that process uh which is so I I moved to New Haven Connecticut to grool and in the process of that started working with um some great Folks at the LA's program and then really just kind of latched on to more how can I help support um substance users marginalized gurus to really um get the care that that they deserve and so started actually doing a research career because you know when you when you're not sure what you're supposed to do you should ask questions and get data and do research so I started to do that got a little frustrated with the fact that things that are discovered in research don't always make it to the bedside and the patients that need them most and so started to kind of drift away from research to program development and had the opportunity to support work in Ukraine since years ago before the war um and in East Africa Tanzania and Kenya I name UK to really start trying to think about how do you design novel ways to bring evidence-based care to the people that need it most and so it just kind of really got me excited about system change and how do you make a difference in the world and the people that you're with and so kind of fast forward in back stat side worked in kind of Public Health Systems and really became increasingly interested in the digital space because there's so much potential but there's kind of this Grand irony a lot of what we do in the face-to-face interactions with patients is the same as it was in the 90s when I was charting on paper right the kind of interaction we're having the difference is that now there's this computer that's involved in the room and a lot of medical people view the computer as the enemy right it's my liability it's not my asset and so I started to increasingly think about well wait I mean the computer should be an asset it should make things easier it should help with documentation it should help make sure that I don't miss that abnormal lab that's sitting out there it should help me with patient safety it should help me with identification and so that uh kind of moved me from New England to Northeast Ohio to start really collaborating on the operation side of the house how does operations work collaboratively informatics um with the faculty to start to re-envision that connection between the provider the provider of care and the technology provider and how do we actually make a better system of care delivery right instead of we'll just do what we did in the 990s we'll take the piece of paper and make it a Word document in the computer program or the electronic health record 21st century my my phone is smarter than every computer I used in the 90s in the 2000 like it's so why isn't my interface with electronic health record better than it was in the 9s so that's kind of where I landed lot to unpack there I actually CU I know we've talked a couple times I didn't realize that the the work that you had done surrounding you know I mean you mentioned the a epidemic you mentioned substance use disorder um I'm really passionate about that as well per my mom's nonprofit what they're doing with trauma informed care and you know changing the way we treat substance use disorder in the state of New Jersey and hopefully soon to be Beyond so yeah that's that's really cool I mean it's so important uh such important work because substance use is a a symptom right it's not a people that that use substances are they have been traumatized more more often than not there's something there and and the the the use of a substance is just a coping mechanism an ill- fated Co coping mechanism and it it more often than not they have a a chemical disposition that you know perpetuates that that use so it's just uh so often it's mistreated too right which is a shame like I think that nationally there there's a lot of issues with um you know a lot of the ways that we treat substance use disorder so anyway the fact that you were working towards that I I really appreciate and uh and what you said about the way that we're using technology and what I heard was really to just to improve The Human Experience right to use it as a tool to to to be able to connect more and become an asset rather than a liability I love that so you've had a a really interesting Journey Doug you know what what would you say is one of the most important things that you learned and it could be personally professionally or otherwise and just if you're thinking about kind of what life was like before that and after that maybe you could just share um you know what comes to mind I think one of the biggest things that I've had to learned over the years is certainly everything in healthcare comes down to behavior change and a lot of healthcare has mistaken the behavior change idea as a rational information kind of um transactional conversation right you have diabetes stop eating sugar take these pills like we're done I've told you what to do you should go do it fine you come back you haven't done it oh you're bad like maybe you didn't understand I'll give you more education so most of medicine then is this assumption that people don't change Behavior out of ignorance and that that's a Hallmark of how medicine approaches people and I think that's fundamentally wrong I mean I'm not saying you don't need to be educated you should know what diabetes is but but people aren't struggling in their diabetes often because you know I didn't believe the Doctor Who said that diabetes is the leading cause of blindness but I don't have transportation I can't leave my job I I can't I was link to the eye doctor and they canceled my visit right we're we're not really factoring in what does it mean for me to prioritize my health I've got kids I'm a single parent I'm homeless and so working with people who's drugs working with the homeless I learned a lot about how challenging it is to make any change changes that I would have thought were easy it's like well you know if I'm if I'm better resourced if I'm whatever those changes might be easy but then I had to stop and say well you know actually you know kind of shame on me I might even have more education on this disease but I'm struggling and I learned that in the AIDS epidemic too we would have the you know we'd have residents who would be all upset and like w why doesn't he take his pills every day I'm like look do you have to take something every day at the same do you have to take something multiple time so we would challenge them get a bunch of jelly beans I want you to take like a green one every day in the morning take a you know a yellow one at night and see how you do and invariably you know any honest consumer um would be like yeah totally forgot oh but then that's because I'm a resident that's because I'm tired right we all have excuses for our behaviors but that's the Hallmark it's like yeah you have a reason for what happened the patient has a reason for what happened and so I feel like more and more where Healthcare needs to move and where I would love her technology to help is to help remove some of the documentation stressors that support the transactional relationship right okay I've got all of these checklists let me check off you're this you're this you're this it's a just TR actional right it's just it's it's not really a conversation it's not a relationship but Behavior change is about a relationship and and this really hit me when I was um this there's there better hepsi treatments now but you know 15 years ago we were doing old hepsi treatments that made people really sick and depressed and lose their hair and I remember you know a person who uses drugs just looking at me saying well you know I really don't want to do this treatment but you tell me that it's important to do it and I trust you and I I thought well wait like this person is reprioritizing like and these were you know the treatments are now 8 to 12 weeks this was 48 weeks of treatment right this is like I'm going to you're going to be miserable for a year I'm willing to do it because I have a trusting relationship I'm willing to change my behavior not because it's transactional not because you told me well if I don't do it I'll get sosis and die like not because of all of these other datadriven pieces that people think Chang the calculus of my behavior but it's because of this relationship that we have and as I kind of moved on through life and started reading more about behavi economics and about how people don't really make rational decisions often right we make these kind of emotive humanistic responses to the things that we encountered life and then we kind of go back later and justify what we did started to make more and more sense man in medicine I need to focus on how to help people how to kind of we're in the words of Richard ther how do I nudge people how do we change the choice architecture to help people make better decisions not in the paternalistic qu but understanding that it is incredibly hard to change your life for some weird future probability if you don't do this you have a 10% chance of dying six months earlier 15 years from now like nobody knows sense of the information that Physicians provide some time so that was like a long answer to a short question no I mean it like so good though uh I'm trying to think of where to start I mean what I what I heard too was like how are we making treatment and and Medicine more personal right like how are we creating that 360 degree view of the patient like they're not just their diagnosis it's those other factors that currently don't live in the e right like there just not there's not a space for it there right and and it's it's hard to to access you know because like when you're seeing so many patients like how are you making it easy to recall all of that and and and really spending the time to get that data in the first place like it's a tricky Paradigm but you know I think about like going back to substance use disorder like in the 40s you know Dr silkworth an Ohio doc like wrote about the fact that like it wasn't like like alcoholics and addicts like like they couldn't solve their issue with sheer willpower like the behavior change had to come in a perspective shift and we've seen that serve millions of people that sub like suffer from substance use but it did it wasn't just like hey stop doing that like here's the knowledge of how much these this drugs and this alcohol is affecting you now stop it required something else and like when you mentioned the diabetes example right I like above and beyond like TR Transportation I I like wasn't thinking about that either or like other socioeconomic factors like what about the guy who's you know addicted to food as a coping mechanism for trauma he experienced as a child right and like how are like so so to treat something like that I need to treat the trauma not the eating right and then the eating will follow but if I'm not treating the underlying you know issue it's even if I do something temporarily it's likely to resurface in my experence oh it's so true I mean think about um in the Obesity world right there people can do surgery to help do weight loss or you can take a medication and get some weight loss but people are able to still gain weight even after these things are being done right so to to your point um if you're not treating the disease you're treating the symptom right so I'll tell people all the time here you know the treatment for pneumonia is not Tylenol the treatment for fever is Tylenol but we actually want to treat the pneumonia right we want to treat the underlying problem and so we've actually started on the journey uh for diabetes and so I asked the hospital to to flip around its view and say what is the hospital's responsibility to every diabetic right not what does every diabetic need from the hospital which is normally what we think but instead say no what's Our obligation right if Our obligation is that we want to make sure that everybody has Equitable high quality Health Care understanding that people come from I mean we're a safety inet Hospital people come from all walks of life what do we need to make sure every diabetic knows well we should probably make sure that they do have some understanding of their disease right right now education happens in all kinds of different ways it's not standardized I don't know some person got a great education from a health care provider this person over here you know we did right we just kind of dro the ball so but then you know one of the things I started to challenge the team on was okay well it's not just about creating educational package we have to get it to patients it has to be in a way in which that they can understand in the right language the right culture the right context but then we I I I hate this idea that the patient Bears the burden of everything right so the patient's going to navigate the phone tree and get an eye appointment like that's crazy we know who the diabetics we know who got an eye exam and didn't we should own calling the patient and helping them be successful right that's that's a high quality Equitable system instead of just saying well it's on the patient well if right that's assumes that they've absorbed a transactional rational status of I know the probability of me getting diabetic retinopathy and going blind no nobody knows that right we need to instead go out nudge help support get that a problem solve why can't you get to the eye doctor right is there maybe our Hospital doesn't have an eye doctor close to you but maybe there's somebody else let us help connect you we need to reinvent the way we interact with Pat and it's got to be around Behavior change and it's got to be more supportive and inclusive than it is I love that man yeah I reminds me of two things one is you know I I was lucky enough to be could go to DC a year or two ago to participate in this forum the National Academy of Science engineering and Medicine did on follow-up care for traumatic brain injury and just the fact that a lot of these folks ended up having these acute incidents where they were in a car accident or they got tackled in football or whatever and they had a concussion or they had whatever and they were treated and then they were released and there was no firm follow-up care plan because there were no the symptoms were gone but then sure enough 6 12 18 months later people would start getting headaches people would start suffering from depression and when they started getting the mental and emotional effects of the TBI they became less likely to follow up with their healthc care provider because they were getting sucked down into the muck and the health system had lost their tether so these folks were just floating out and God knows if you're suffering depression like what that can lead to right um so how am I keeping that tether and that that personalization such that you know I can ask somebody like as opposed to just asking for their their birthday and their social security number I can be focused on like Doug you know how are you I know you you went through this this traumatic incident like a little over six months ago how are you feeling and just shut up and like and really absorb that and the the interesting part too right is like for some of those things it doesn't necessarily require a Clin right like we can do that certain followup without a clinician just with someone who cares someone who cares and then the other thing that makes me think of is Guthrie out of SE Pennsylvania they've created this pulse center it's really interesting it's it's this kind of extension of an Access Center where they're they're kind of building the different parts kind of in a connected fashion where they're connecting T Health and they're connecting this and it's just the the way that they're trying to build out that connection throughout the Continuum and it's still a work in progress is really cool like I think that's like that's where I see Healthcare going uh in the future and getting the basis such that then I can work on the front end in a more preventative fashion and I think that for me personally too as a patient the more personalized my health system can be in their Outreach to me about about what I need to be doing to keep my health right going and and and why the better like I'm 37 I think it was like I just met with my primary care physician like a couple weeks ago she's like you're going to need a like colonoscopy in a few years I was like all right great like but now I I know and I know that like when you hit 40 or whatever it is like that's just what you got to do you know yeah so I think it one of the things that we did um what the last year we say we started so kind of back to your proactive piece right 40% of diabetics statistically on average have major depressive disorder it's not really clear if that's due to something biochemical if it's due to the fact that it's just situationally really depressing to be like oh my goodness I've got this lifel loone disease you know so whatever the cause as you're pointed out if someone's depressed they're withdraw disengage from Healthcare right disconnect and so so my challenge to the team was like look if we know that diabetics have a high probability of having depression are we screening all of the diabetics for depression when a diabetic disconnects from if they miss a refill are we proactively reaching out to that person right if we're framing this not as well I you know Doug just stopped his it you know it's his fault like kind of the traditional blame blame other people if instead we turn this around and say Something's Happened and it could be something medical right because often we also think maybe okay well maybe it's the social determinance of Health maybe there was a copay problem maybe there was a whatever problem all legitimate problems all of which the hospital should try to help address but there could also be another medical problem right and it might be you dong topress we need to connect and we need to screen maybe he needs help and it could be medication help with depression it could be therapy but to your point too often Healthcare sitting there waiting but the future needs to be how am I being proactive and then technology gives us really novel ways in which to start thinking about that right how can I mean you know I'm always amazed at how nice chat Bots are to me compared to the human that I talk to when I call in some place it's so funny that you mentioned that Dr Stephanie leir has some studies showing that like because the a lot of the times you'll hear how her Bots going to be empathetic she has a study showing like the empathy of of virtual Bots and AI versus some traditional you know just people working in an Access Center or otherwise um much time as they need right like it's not on a t CL it's it can be patient like you're just sitting there yeah but where where could that be proactive right you're you missed your refill what's the immediate Reach Out do we wait for a human to get free to begin a reach out or is there some kind of automatic reach out hey just checking in are you okay is everything all right I see you missed your Ro right because as you're talking about it the the person the human being is looking for connection and I've heard it too often in safety net systems where the patient says well you know nobody called me I missed my appointment I missed and and the system may have actually tried to call but it can't try infinitely mod can kind of infinitely reach out to you right so where are the ways in which technology instead of focusing on the transactional aspect and I'm not saying that there isn't a need for transaction I'm just saying we're going to help build relationship because if if the patient is man you know I missed I missed it it wasn't even 24 hours and I was getting messages about this and and you know they're framed appropriately the person can interact with them however it's designed but if I I feel connected maybe I should you know that doctor cares about me it goes back to my hepc patient he knew that I had his best interest in mine and I wanted to help him he trusted that and he was willing to do treatment and get cured but if I didn't have that relationship he would have been dismissive of me because it wasn't about the probability of cure and the possible benefits of cure it was all about the relationship for him yeah I mean and I I want to learn a little bit more about some of the initiatives you guys are working on at Metro Health and stuff like that but I mean this has been so good the last thing because you you brought up that and this is all working towards evidence-based care right in my in my opinion right and one of the things that I mentioned my mother nonprofit like they're very big on evidence-based care they have a partnership with with Ruckers and and I actually want to start working with some of the north east Health Systems because we we're talking with uh hims about their AI center of excellence and what we might be able to do to impact maternal mortality rates particularly for for African-American women or or other marginalized populations and my mom with her research has has evidenced the fact that upwards of 80% of those women suffer from either mental health or substance use disorder and it's not being treated effectively currently right right and that's that's a that's a real problem um on so many different levels so it's like it's not just like that's that's the we have to impact the the The Root versus the you know and I'm just I'm really passionate about that because I I think it affects so many communities nationally and it's really it's not talked about it yeah no I think it's super important yeah it's interesting so cognitive behavioral therapy there's manualized programs that that folks have developed and I know Kathy Carrol years ago was working on this at Yale and and basically trying to create a computer interactive program where a patient could sit down and of course computers are a lot smarter than they were back then um but it would be really fascinating right to think about how could the patient be screened identified as having depression and immediately be connected into something and I'm not saying that a computer program can replace a human therapist but when you think about the um shortage of mental health providers in America and the huge burden of mental health disease even a program that could begin a CBT process and start to scream right I mean you know one of the things that it's um so I like tell the sub Specialists here right my my goal is not to give every patient with a pair of eyes to an optomologist right because my opt the Opthomologist and they've divided the the retina doc needs to see abnormal retinas to do surgery to help that patient I'm not going to send an 18-year-old with normal retinas and who needs glasses to the retina dock right that's a misalignment of resources and it's not I mean I don't think it's a good use of resources to send every depressed patient to the same level of therapy when some of them would have been fine you know with a manualized process for CBT I need to send the person that that that won't work right oh you really need to see an actual therapist or it's it's not actually you know major depressive disorder you have you have bipolar disorder you're going to need some medications and some specialized therapy to be able to have a system that could deployed and help us Tri like helps everybody some triage to those who are more complicated and escalate them to an evidence-based program would be fantastic and it's interesting to me that people are scared of those kinds of things but I have to remind you know our hospital and other Hospital systems that wait you know right now what do you do you're not even you're not screening all the people that need to be screened and the people you have screened who have a problem are waiting in line for an appointment and you know that was in research for a long time so say what you've done is you've randomized them to Placebo right they're they're waiting for an intervention but they're not getting anything while they wait now people might say well you know I give them an SSRI or he's on some medication and yes that can be helpful but depression is complicated there's a biochemical issue but as we know there can be a lot of Trauma Life related issues things that you need talk about and medication and waiting in line doesn't help with the things that you need to process through app so yeah I think the ways in which we could start moving in that direction as well be super helpful as we try to make sure that nobody gets left behind and sometimes people get left behind because we just don't have enough resources and where technology can be an added resource that's a huge value add to people yeah agree and I think think that it also needs to start earlier and what I mean by that is a lot of the the imprinting and the trauma or the you know what have you starts early five years old you know as you're you know becoming a young adult into you know so how am I like when that and and the the truth is that that that student that 12-year-old student right who's going home to you know a traumatic situation with one or or more like two parents whatever the situation is they can't talk about it there right so H how am I better arming like the teachers and like I I'm not saying like like we don't expect the teachers to become clinicians but you know how am I teaching more Educators about trauma informed care and how to engage how to see the the warning signs because if I can treat that child before they develop substance use disorder that's going the the the delayer deeper right it's affecting uh things on an exponential level because it's not only that that child it's it's generations to come right oh totally agree and I mean you know so some of what we're trying to do in that space is have Partnerships with schools directly and so in some places we people to the schools we've got we have a clinic sitting in a school um so a lot of that's trying to provide for the physical and mental health needs of students but to your point right often times it's when things get really bad that people start to notice but usually a lot has gone on to get really bad and the more you know I used to say when we're doing a lot of harm reduction work was you know our our goal is is to get people before they put a needle in their arm right because I don't want or if they're going to put a needle in their arm that it's a clean needle because that there's a whole lot of Downstream consequences when you get Pepsi you get HIV you get other things that become more and more complicated to treat and have their own biological consequences and so to the same point um it's easy to be like oh well we don't want people to get viruses but if you think about trauma and being depressed they have have their own consequences and there's a lot of human suffering that goes on that's just masked by the fact that we don't have time for each other and we're in these transactional relationships but the more that we can start to identify people and then connect them into care and the earlier we can do it the better so that we can try to really avoid that young adult seeking to self-medicate depression with a substance then leads to a problem and then you know a decade or more later after having significant consequences to the substance use winds up somebody trying to help them with that but then may be missing the root C and so I think there's a lot in the space and the more that technology helps us identify populations that need help and help prioritize those populations so that Hospital systems like safety net systems are able to prioritize and understand well I mean I've got 47,000 diabetics that I need to make sure all of them get an eye exam this year that all of them get a foot exam that all of them have a hog gliny that all of you know but it's very challenging to know where all of those people are all of the time and to know where they are in the Continuum of Care and where we can actually intervene I got limited resources so what's the technology that helps me manage a big ocean of people and then flag those who need individual human attention so that we can make sure that we're you know connecting the right patient to the right person at the right time right and and the tricky part it goes back to what we said like a lot of those factors that I would want to incorporate in that understanding of a patient in order to prioritize them effectively and support them appropriately do not necessarily live in the EHR um today so how am I you know augmenting that and and what certain ehrs are doing now with CRM as an extension of the core functionality is solving for some of that and you know it's an evolution but yeah really interesting stuff I mean I mean time has has flown Tu this this is awesome I I do want to ask I always like to ask what favorite book or or a book that you've read recently that you might recommend to our Le listeners it could also be a podcast or or other type of literary piece again either all time or recently your choice so freeden hunman from Bas Camp wrote a a book that they published relatively recently called things don't have to be crazy at work and so you know they're at base camp and so their their argument which I found fascinating because I don't think of the tech industry as arguing for a 40-hour work week and um certainly medicine's never argued for a 40 Hour Work Week um but they had this fascinating argument that um so much of our lives are interrupted by technology and because we get interrupted lots and we get interrupted at work whether you get a you know instant message from somebody about this or an email or you know you get all of these things where you're supposed to be constantly available that you can't get into the flow of work um you know there's a whole body of literature on Flow but this that idea of I need a couple solid hours where people don't bother me so I can actually make progress on things and I would say since going through that book I have just been paying attention to a lot of the meetings that I get sucked into but I'm like what like why are we meeting could this have been an like what's going on here and you know it's it's interesting because it's almost like people are using the guise of some transactional thing like we need to get together to do X when X doesn't seem to be what the meeting is about it seems like we're kind of having just a relation conversation right and I'm not saying relationships are important but but the reality is man I'm not getting anything done and now I'm more stressed and now I've got all this other junk to do and so I would recommend that to people you may or may not agree with all of the premises or arguments but but it's just really fascinating to hear of a group that for the last 20 years has made having calm be something important at work and having and providing people with space to really get into the work and to do it well and it's made me start thinking more and more about how we interrupt Physicians and nurse practitioners and P other people when they're trying to do their documentation right we interrupt them you're you're trying to chart and we send you secure chat through the EMR and you're like ah now I got to deal with this and I can't or they get a call or a page or someone knocks on the door and you you can you can never pick up where you were like an audiobook you're like okay I got have to rewind and then I have to relisten to this in order to figure out where I am and so right we're we're inefficient and then we we miss things because like well I interrupted you when you were thinking about I needed to order this lab or do this Imaging or do this referral and then I forget or I'm asking the patient do you remember what I was and and that impacts the quality of care and so I just found that more and more interesting of how do we start protecting the provider's time so we've actually started talking about um right now a lot of the healthcare providers here have kind of charting time spread out throughout their day in which they're doing care and so I'm starting to make the argument that I want to pull all of that out give blocks of administrative time and just say look be off campus I don't care where you are but you need to have some protected time so that you can be efficient and you can do the clinical documentation work you need to get done you can really reflect on the care of the patients that you're taking care of in a way in which you're not being interrupted by just the health or sculpure nature of a hospital Sy that's cool I mean I love that and it's it's true for me it's something that I've had to look at base camp is like the project management Cloud ration software tool is that right yeah I got to check that out but yeah this is how I build my my reading list so uh Doug this has been awesome we pretty much out of time the LA the last question I just like to ask all my guests is if you could go back 5 10 15 years in time what advice would you give your younger self I think I would tell my younger self focus on the doing good and take more risks there there's so often times where I would say I was overthinking the situation and I feel like if I hadn't been so I was making the the perfect the enemy of the good and if I just focus on this is good enough work F like do just get this get this launched take some more risks feel like we could have done more good that's what I hope to do in the future I love that that's I feel like that that in essence is the root of of innovation really you know as being willing to have it Having the courage to take that risk which for me was similarly uh gained through time and and perspective and and all of that but then you know incorporating that feedback and then moving forward to the next iteration right and see I'm seeing more and more of that in our industry as a whole a slow roll but it's really exciting and clearly uh you're on on the Forefront of it so Doug such a pleasure having you on thanks so much for taking the time thanks for having me it's been great love the conversation always love chatting with you yeah me too to our listeners thank you for tuning in we will catch you all next week [Music]