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Manav Sevak:
Welcome to the Memora Health Care Delivery podcast. Through conversations with industry leaders and innovators, we uncover ways to simplify how patients and care teams navigate complex care delivery.
Matt Troup:
Hi, everyone. This is Matt from Memora Health, one of the medical directors and co-hosts of the Care Delivery podcast. I'm excited today to be joined by Dr. James Cireddu. James, thank you so much for coming on the podcast today. Can you take a moment to introduce yourself?
James Cireddu:
Yeah, Thanks, Matt, for the introduction. I'm James Cireddu, a medical director and invasive cardiology with the University Hospitals of Cleveland. I'm also CEO and founder of VPExam of TeleHealth Care Solutions.
Matt Troup:
Awesome. I'm excited to dig into some of your more recent experience, but always love to know from our guests what inspired you to do the work that you do currently and what continues to drive that passion.
James Cireddu:
Yeah, so as a practicing cardiologist over the last ten years, I always saw a lot of potential in telemedicine, even before there was reimbursements and widespread use, mainly around the time of COVID. So even back in training, I started trying to get awards and multiple moves from the National Science Foundation to help develop innovative technology that could bring full cardiac care to underserved populations. A lot of my passion was around elderly patients who have a lot of transportation, financial, geographic, and a lot of them may reside in places where they still can't get great access to care, like skilled nursing facilities. So that's really been our passion around VPExam is bringing full cardiology care both asynchronously and in real time to our patients, regardless of where they end up, whether it's in skilled nursing facility, whether it's at home, whether it's with home care, or even long-term acute care facilities. It was just a lot of patients in need, and we thought we could bring that technology to them in full cardiac care.
Matt Troup:
Yeah, James couldn't agree more. I would love to know, from your perspective, what makes cardiology, and specifically heart failure, an area of medicine that is really in need of further innovation.
James Cireddu:
Yeah, that's a great question. I think we've all become more and more familiar with telemedicine, and a lot of it is just run-of-the-mill video conferencing kind of calls in a HIPAA-compliant package, but for cardiology and especially for heart failure, the physical exam is really critical. And I've worked with a lot of platforms that try to use different parts of the physical exam, maybe they use parts of a stethoscope to do a heart and lung exam, and I found that even if you have great hardware, the problem is if the person on the other side doesn't know how to use it, that's a big problem. It's going to be very inefficient both for the nurse or the technician on the other side and for the physician who's trying to get that information back to them to take better care of the patient. And again, for cardiology, that's really critical to manage these patients appropriately. There's a lot of other things like post-myocardial infarction, or somebody has had a heart attack. Patients who have had atrial fibrillation, arrhythmias, the physical exam plays a big role in how we care for them. But in heart failure, looking at things like jugular venous distention, lower extremity edema, we are adjusting very powerful medications, and if we don't understand what's going on physiologically, we're flying blind. Run-of-the-mill telemedicine, good for our well patients. I usually say, if the patient's doing well and it's a well follow-up, we can just do regular telemedicine. But VPExam's real focus was using augmented reality training so somebody who's never even used the platform before could pick up the app, use it, look at jugular venous distension, lower extremity edema, position patients appropriately, and get real-time feedback without bugging the physician or nurse practitioner or PA provider, and give them that full exam so that when they log in, it's very time efficient. So it's almost the same level of time commitment as a regular telemedicine encounter, but they have a lot more data, and we can walk them through using these more sophisticated medical pieces of equipment, whether it's a stethoscope with EKG, it can really walk them through step by step how to use it and making sure the data is good quality as well.
Matt Troup:
That's amazing. And when you think about COVID pandemic, and I think that it really exacerbated or catalyzed a lot of our use of telehealth out of necessity, it seems like probably the physical exam has lagged behind in a lot of ways, given that most of us are during the height of COVID, we're using any sort of video technology possible, but no way to listen to heart or lung sounds. So, have you felt additional pressure, would you say, in the last couple of years, to move this technology even further along? Or how has been, what has been the reception like to this sort of virtual-physical exam?
James Cireddu:
Yeah, it's an exciting time. The telemedicine has been a crowded space. Remote patient monitoring has been more recently a crowded space. But we have fairly unique tools in this virtual-physical exam, which is what VPExam really stands for, that kind of helps set us apart from the crowd. So we've had increasing adoption, and then we've had a few publications over the last year that have shown some of the power of this technology. One of our biggest was focus on using this technology as we discharge patients from the hospital to follow these heart failure patients throughout their transitions of care, whether they were going to a nursing home or they had the ability to be followed up by a home care. And we were able to see them within one week of discharge, and our 30-day rehospitalization rate dropped by over 40% for the relative risk reduction, and even our 30-day mortality rate dropped over 56% for these complex sick heart failure patients. So that was a better outcome than we even expected, but those kind of publications have been fairly powerful for getting new clinical partners to adopt our technology. And then, even last year, we were invited to the Heart Rhythm Society, HRX. We received one of the awards for Breakthrough Innovation in Cardiovascular Digital Health. So that's also been a nice recognition from our peers that this is innovative technology. The augmented reality combined with some of our artificial intelligence alerts for even just smart wearable data is really changing the way we can monitor, and we can intervene on those kind of patients.
Matt Troup:
It seems as though this technology is certainly primed for the transitions of care period. What makes that period so vulnerable for patients with heart failure? And do you see this technology also playing a role more longitudinally in care as well?
James Cireddu:
Yeah, so these are very challenging patients. Of all the cardiac patients, I'd say the heart failure patients are probably the most challenging that I take care of, and you start with a challenging statistic, which is, this is the number one cause of hospitalization for patients over age 65. It's costing over $43 billion a year. You have over 6.5 million Americans who have heart failure. And you think that's a huge number, there's got to be a lot of resources there, but almost a quarter of these patients are going to be readmitted to the hospital within one month of discharge. Almost 50% are going to be readmitted within six months. That kind of just goes back to there's a lot of things going on physiologically, there's a lot of complex medications, so they don't just impact the heart; they impact the kidneys, they impact the liver, and we have to carefully monitor all that. They impact the blood pressure. We let the patients run with blood pressures that are too high, they can go back into heart failure. We let them go too low, they get dizzy, they pass out. We under… them, they come back to the hospital, we overd… them, and we shoot their kidneys, and they're they're going to go into acute renal failure. We have a different kind of problem. And then, in the background, there's a lot of other complications, arrhythmias from abnormal electrolytes. We let the potassium, the magnesium, the sodium get out of range, that's a different kind of problem. The wearables make a lot of sense. The Bluetooth-enabled biometrics make a lot of sense. And that's why I think there's a lot of potential for remote patient monitoring. The ones that we use the most is we hook into the patient's Apple Health, Google Fit. We can follow their smartwatch data so we can see even early on, hey, they become tachycardic, and it'll send us an alert. Now, some of the newer watches can do an EKG. We can actually see, hey, they've gone into atrial fibrillation. They can transmit that to us. Then, that can act as a trigger. Other triggers are pretty straightforward Bluetooth blood pressure cuffs, a Bluetooth scale, Hey, they've gained 5 lbs of weight. We get an automated AI-based alert that they're decompensating and probably putting on fluid weight from their heart failure. But the nice thing is, with VPExam, now we have a tool where we don't have to say, Hey, you have to come to the clinic, hey, you have to come to the emergency room, Hey, you have to come back to the hospital. We can deploy the technology either when we discharge the patient from the hospital, they can use it themselves, they can do the full physical exam and send it to their provider. So now we have a lot more confidence in changing their diuretics, changing their antihypertensives, and things like that, or we can send the home care nurse out to their house with the equipment and pretty much do a lot of this at bedside. And even the expansion of things like hospital at home, we can actually put IVs in the patient to give them IV diuretics like Lasix and things like that. In new settings. We have diuretic clinics where we can do it as an outpatient, but now we can even do it in the home environment, which is pretty much a big game-changer. Diuresis is really the cornerstone of a lot of our heart failure patients, and the combination of wearables with a full augmented reality physical exam with the ability to really quickly as a physician act upon that data, that's where I think the future is. And yeah, the other side of it is incentivizing physicians to want to be part of this kind of care. I think that's where, I think there's a lot of interest is the reimbursement. When telemedicine wasn't being reimbursed, guess what? Nobody was using telemedicine. That was not that surprising. With VPExam, we can attract that higher level of complexity, usually we'll equate to higher level reimbursement, but also remote patient monitoring. That's a different kind of reimbursement. I'll say, as a physician, a lot of the problems I've seen with remote patient monitoring, there's a few, but the biggest is if the physician is not involved, they're not documenting that they reviewed the data, and they're not utilizing it to change the care management of the patient, and that's not all well documented, you really can't bill for it. So I've seen a lot of excitement around remote patient monitoring, but actually getting it into the physician workflow is a big challenge, and that's been one of our focuses. Because otherwise, as a physician, you either get this fatigue from all these alerts going off constantly, but if it's not part of your daily management of patients, and that's what I think a good virtual care platform can do is you get these alerts, but then you're tied directly to the patient via the app, via the web portal, and you can talk to them immediately. You have all that data funneled, whether it's web-based, whether it's integrated into your EMR, and then that makes the billing side of things, the reimbursement side of things, the RVU that everybody's being monitored on, it makes it make sense is that you're actually getting all the credit for the time you're putting in that you really deserve. And I think in cardiology, that's key, because if you're just getting a lot of burden but you're not getting the measurable reimbursable side of the care providing you stop using those platforms, and you have to go back to seeing patients back in the clinic.
Matt Troup:
Yeah, it feels like another task that builds up and just increases the burden, and then that complicates the care and moves us more towards burnout. Yeah, I totally agree with that. Yeah, again, highlighting that stat you mentioned about the readmission rates and the probability of a patient with heart failure readmitted to the ER, shows that this period is so crucial to quality care. Speaking of adoption now and reimbursement, what has it been like for you as you've seen maybe fellow cardiologists or spoken to other cardiologists who are potentially adopting this type of technology? Is there a resistance to it? Are they being able to see the potential gains and improved outcomes, or is it still an uphill battle?
James Cireddu:
Yeah, so the adoption has been very good, actually. Most physicians, NPs, PAs really like the data. It's there, it's easy to access, and it all gets embedded into the EMR if they want. So the adoption's been good. What I'll say is that the bigger trends I've seen in telemedicine was, during the pandemic, a lot of us adopted it, and that's been good, but I think there's almost a recession of adoption of telemedicine, not because there's no reimbursement, but I think we've all some people got burned out on it for different reasons. But again, I think a lot of people just, they used it because there was nothing else they could do. If you're going to have patients come to your clinic, telemedicine made better sense than seeing nobody, and patients would rather be seen, I think, a lot of the time in person because they think they're losing a lot by telemedicine has been the feedback. I'd say that's one of the biggest things, we've had a lot of positive feedback, both from patients, family members, even nurses who are using it as they feel like it's virtual care, it's a kind of telemedicine, but they're not losing all those touch points that they expect when they come to see us in the clinic. I think that's what the physical exam really adds back. So, I think it gives the physicians and the providers a lot more confidence in their decision-making. Some of our AI tools are really around, A, we give you the data, and we make it, we make the alerts very customizable. We make your schedule very customizable. I'll say that's the other part of telemedicine as I've come to realize there's different kinds of physicians, some of us just want telemedicine, let's say 9:00 till noon, and that's it, and maybe only one day a week. And some of us want to be available almost 24/7 because maybe we're the medical director of a nursing facility or long-term acute care facility. And that's one of the things we built in VPExam as well, is to make it very customizable to different kinds of physicians so we don't run into that burnout, because nothing's worse than a tool that is not doing what you want it, which is making you available to your patients more often. But you've got to make that customizable because there's just a lot of different ways physicians, nurse practitioners, and PAs want to practice, and I think we try to make our platform very customizable on that side. Even to the fact where you can use it on a mobile device, I've actually looked at a physical exam of a patient while wearing my ear pods at one of my kids' soccer games and then video conference into them. Not really the way I ever thought we would be able to do virtual care, but its, flexibility goes a long way, and nobody wants to eat, drink, and breathe medicine 24/7, but it's nice when you have the flexibility.
Matt Troup:
Yeah, monitoring … at a soccer game for your kid, and commenting on it is, yeah, the new frontier, I would imagine, of cardiology. You hit on the patient side of things, but yeah, I would love to double-click on that. When you mentioned about the patient satisfaction, I'm sure there's a component of empowerment too in this and that, you know, what would have been maybe a clinic visit, or even worse, like an acute care visit, is now something that they can do even remotely, but still have the confidence that their clinicians have all the data they need to make the right decision. So it sounds like that's what you've.
James Cireddu:
Yeah, we really put a lot of focus on the feedback of the patients, and a lot of our patients and family members have told us after using this kind of technology, they would never want to go back to just a traditional kind of videoconference, only telemedicine. And the augmented reality, there's a gee-whiz factor, and when they see a Bluetooth-enabled stethoscope that can do an EKG in real-time, there's a gee-whiz factor. And we can talk to them while I'm on the video conference, and we can turn on the stethoscope and can transmit it in real-time while I'm talking to them, they appreciate all of that. But really, at the end of the day, it's the better outcomes, and it's that we have more confidence to manage them in these kind of new frontiers, which is really even in the patient's home, which is the way healthcare is going, less hospital beds and more hospital at home kind of opportunities. And I think this kind of technology is really appreciated. Even in our studies, we're carefully monitoring patient and nurse satisfaction, and our patient satisfaction averaged 4.9 out of 5. Really, we really were keeping a close eye on that, and we redevelop the patient-facing side of the app pretty regularly to make sure it's easy enough to use. Even the patient can use it themselves.
Matt Troup:
It's incredible. And speaking of that access, and something important for Memora is we always think about meeting patients where they're at because care doesn't solely happen within hospitals or clinics. You know, I've heard you talk a bit about serving an underserved population. And do you think digital health is doing a good enough job decreasing barriers and improving access, or is it still complicated by cost and some other new artificial barriers?
James Cireddu:
Yeah, I think it's definitely helped. I do think there's a lot of patients who, cell phones become ubiquitous, and at least them getting access to physicians is a big step in the right direction. A lot of our elderly patients, I do think there's a, your comfort with using technology barrier that's definitely still there. Even for VPExam, we understand our 80 and 90-year-old patients who may be the same age as our grandparents aren't going to necessarily be able to perform physical exams on themselves, and that's why we've really worked to bring the service side of virtual care to the patients. The logistics of making sure that you have home care agencies that feel comfortable using your technology, that's really key. And also being tied into the home care agencies, and we've even worked with paramedics who can bring VPExam into the home setting, and that's how we can use it for hospital-at-home kind of settings as well. I think that's big because if you're a patient, I've got a decent number of my elderly patients that don't have smartphones, and even if they don't, they just can't even make use of it. You text them an SMS text where they just have to click on the waiting room, and it should pull them right in, and somehow that's gone awry. I will say when you can't, you can lead the horse to water, but sometimes it's definitely helpful that you can tie in different sides of the service where you can bring the cardiologist into the patient's home and into the patient's nursing home. That was always our bigger goal.
Matt Troup:
Yeah, I totally agree. And shifting gears a little bit, as you think about the progress that's been made in virtual health, and recently had an experience where was called for a medical emergency on a flight, and the gentleman had an Apple Watch, and so I was able to do the single EKG, and obviously at the moment I would love for a 12 lead or any other tools that were at my disposal, but you'll take what you can get in those situations. But in that moment, I thought, wow, what does the next 5 to 10 years look like when you start to think about how we can monitor patients remotely in locations that we've never thought about before? A flight, restaurant, soccer game. What are you thinking about as you think about the future of VPExam and, ideally, where this type of technology can go?
James Cireddu:
What's exciting about it is physician adoption has been very high, and there's just not been any way of filtering all this data into one place. I think everybody is excited about the potential for artificial intelligence. Some people ask, is that going to push some of the providers out of medicine? I don't think so. There's there's not enough physicians there, not enough nurse practitioners and physician assistants. And one of my children is actually studying pre-med and wants to be a physician. And she asked, Is AI going to replace doctors? No, I don't think so. But one of the things I think is exciting, and we've been putting more and more of our focus and funding toward, is developing artificial intelligence tools to tie this all together; because you can take all of these alerts and then really making the logistics work where the patient is tied into the care immediately with the physician on their schedule. And when you need to deploying home care nurse or making sure the paramedic knows that they can use VPExam in this encounter because their provider is going to use that data, the AI can really tie all these different data points together better than we can now. We started with smart algorithms probably five years ago to …, Hey, These patients need to be seen more quickly, and we need to send alerts to physicians more quickly and let them skip the line. But I think AI can help a lot with triaging and getting the sicker patients with these red flag warning signs to, if not their own cardiologist, a new cardiologist, or somebody in the cardiac care team a lot quicker. I think that's going to be big. The other thing we put a lot of focus on and we pulled all this data together to make it efficient for a physician, or nurse practitioner, or PA to look, but what we didn't appreciate was this expansion of AI. And we've got a system now where you've got virtual histories, review of systems, medication, reconciliation, vitals, smart health data, and a full physical exam, and we've also got the note-taking capacity of where the physicians are making their interpretation of the physical exam and their assessment and plans. So really, I could not have created a better platform to develop the next generation of how artificial intelligence can pull all this data together and learn from it in one place. So we're excited about that side of our platform as well.
Matt Troup:
Oh, awesome, James. It's been a pleasure to hear more about the work you're doing and how you're thinking about the future of care delivery, specifically in cardiology. Yeah, as we wrap up here, I guess, what excites you the most about the direction that digital health is moving?
James Cireddu:
I think it's exciting that there's just so much potential. We see in medicine just the need and the technology is growing quickly and should improve outcomes in these diseases where we just have hit a wall in progress. There's always been new therapies, new pharmacologics, new procedures, especially in cardiology, but the truth is, if you can't get care to these patients because they're in these underserved populations or because we just don't have enough providers, you really got to lean more on the technology to help make us more efficient. And I really think that's where virtual care is going a more efficient way for providers to take care of a lot more patients a lot more efficiently.
Matt Troup:
Yeah, efficiency is key. And I think if we can get to a place where we all feel like we're practicing medicine more efficiently, we'll all be in good shape. So, James, this was a wonderful conversation. Thanks for the time today, and I really appreciate you coming on the podcast.
James Cireddu:
Pleasure and thanks for the invite.
Manav Sevak:
Thanks for listening to the Memora Health Care Delivery podcast. For more ideas on simplifying complex care for care teams and patients, visit MemoraHealth.com.
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