Endless Opportunity: Innovation in Women’s Health
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Endless Opportunity: Innovation in Women’s Health
Podcast Transcript
William Morris, MD: Welcome to Health Amplified, a Cleveland Clinic podcast. This is your host Will Morris and joined with me as always is Dr. Akhil Saklecha. Today, we have a tremendous guest, Dr. Beri Ridgeway, who is the Chair of Obstetrics, Gynecology, and Women's Health here at Cleveland Clinic. In addition to her busy clinical role and leadership role of the Institute of Women's Health, she is also the Associate Chief of Staff and the person responsible for the response for our pandemic readiness and recovery. So with that, please welcome Dr. Ridgeway and Dr. Saklecha.
Akhil Saklecha, MD: Thanks Will. Great intro.
Beri Ridgeway, MD: Thank you.
Akhil Saklecha, MD: All right. You know, I actually, for those of you who don't know Dr. Ridgeway, it'd be great to kind of understand a little bit of your background and how you got here to the Clinic. And then we can kind of dive into what's going on today and what you're doing.
Beri Ridgeway, MD: Great. I'm actually a native Californian and I did all of my schooling there up until fellowship. So bounced around the UC system, which was fabulous and came here for fellowship. I did my residency in OB GYN and my fellowship is in female pelvic medicine and reconstructive surgery and minimally invasive surgery. And when I came here for fellowship, actually for the interview, I thought “Oh my gosh, this place is amazing.” I love the idea of a coordinated system of innovation, of endless possibilities, essentially. And so I put this as my first pick for the match. Fortunately, I matched here and then after fellowship, I stayed on as staff. I left briefly about after six years of being a staff to go back for family reasons, but then returned here in 2017.
Akhil Saklecha, MD: Great. Now tell us, as you've evolved into your administrative role, you're kind of wearing several hats. On the Institute side, what are you seeing now in terms of some of the key innovations, both say surgery, clinical, technology; what are some of the things you're seeing?
Beri Ridgeway, MD: Well, innovation specifically for OB GYN and Women's Health is endless opportunity. When you think of obstetrics, and high risk pregnancies, there are any number of areas in which we are currently developing and then really need further developing. When you really think of how a baby's created, it's really less than two cells. And with that, you get a, in most cases, completely normal functioning human being, placenta and full system to sustain its life. And within that, the fact that it turns out fine, most of the time is utterly amazing. We have a number of interesting things that have evolved over the last five to 10 years. And one of those is prenatal screening, because many parents want to have screening early in the pregnancy to test for anomalies, chromosomal abnormalities. And one of the big developments where I think there's endless possibility, is in that screening. Prior, we used to use ultrasound primarily where other serum markers that you'd put sort of in a formula to say what the probabilities are. We now, with a simple blood test that's done at about 10 to 11 weeks of pregnancy, look for cell-free DNA. So this DNA is from the placenta, actually in the interface with the mom, and with that can do an analysis that's highly predictive of abnormalities like Down syndrome. That's been a game changer.
Akhil Saklecha, MD: Is that, would you say, is that standard of care now?
Beri Ridgeway, MD: It is standard of care now. Absolutely.
Akhil Saklecha, MD: Okay. And where do you see other gaps?
Beri Ridgeway, MD: Well, there's, you know, within obstetrics specifically? Well, I think that the biggest issue that we're facing is infant and maternal mortality. The fact that we're considered a highly developed country and healthcare system, yet we don't measure up to other places in the world as far as how our moms and babies do, is frankly a disgrace. And when you look really at the disparities that we see between different groups, specifically people of color versus whites, it's a huge difference. And I think with that, it's a very complex problem with racial disparities access to care and an innovation there has to do with access to care. Unfortunately, I don't think, at this point, there's any idea or moving towards a, what we would consider, a true innovation in the sense of high technology, but it's access to care, reducing implicit bias, careful monitoring. I think using some innovation and technology can help us get there in that prenatal care and access to that care, access to doctors, nurses, midwives is critical and that's clearly a gap.
Akhil Saklecha, MD: Yeah, actually, I mean, there's a lot there that could be solved. And we're seeing that even outside of women's health, we're seeing it in the delivery of chronic medical conditions like diabetes and hypertension, where there's new cares of delivery models that are evolving. And I haven't seen it yet on the OB GYN side, but certainly that is a huge potential gap involved.
William Morris, MD: Well Beri, I can't help think that with COVID, certainly the lens and the need for Tele-health, distance health has been thrusted into the forefront. You also have social and wealth and health disparities, and you talk about the daunting challenge of mortality and morbidity for maternal, fetal or infant mortality. What have you seen as a positive out of this pandemic? Have you seen a more focused application of this technology, particularly to our most vulnerable patients? Are you seeing the gap widen or are we seeing it shrink? What are you kind of seeing out in the world?
Beri Ridgeway, MD: That's a great question. I think it's a little bit mixed, to be honest. On one hand, I think the gap has increased because there is a technology gap, as well as a lack of consistent internet and other ways to interact. But I do think that there are some solutions that long-term will help narrow this gap, and that specifically with virtual visits. When we, even prior to the pandemic for a pregnancy episode, we had some of our providers offer virtual visits to pregnant patients. So typically a pregnant woman will see a physician or provider about 12 to 14 times in the pregnancy. And we quickly realized that probably four of these visits or more don't need to be in person, meaning you don't need a physical exam; you aren't having a blood test or an ultrasound. And so we created a program where we provide pregnant women with a blood pressure cuff and a fetal Doppler, and most of them will then have obviously a scale at home. And so for those, we're able to connect with them through a virtual visit, check in how they're doing, screen them for symptoms; they can check their blood pressure. We check the fetal Doppler with them, they weigh theirselves and it's nice in that they can do it from the comfort of their own home; it's at a time that's convenient for them, and this is especially for women who have other children, because it's very hard, especially in times of Covid, to access. So we had this program prior to COVID, but COVID being such a disruptor, we immediately shunted really every person who wasn't high risk into this, so that they could continue to stay at home, stay safe there, reduce their own risk of contracting COVID and still get that same amount of prenatal care and patients have loved it. And doctors and midwives who typically did not adopt this prior to COVID, really kind of got into a rhythm and saw, “Oh yeah. This is great”. And I've done those myself for surgical patients for pre-ops and even some post-ops. And there is such value in seeing a person in their own environment. You gain so much more, I think, than you do in seeing someone come in, only come in for visits in the office.
William Morris, MD: That's an interesting perspective, actually, I have not heard. Usually the argument for the recalcitrant physician is: “I don't get that same intimate connection when they're physically not there”, but you're right. I mean, we've all experienced our zoom calls and I now know more about Akhil because I can see in his room. That is an interesting observation; an ability to kind of see the environment in which the upbringing is going on.
Akhil Saklecha, MD: It makes sense. Although, are we seeing that in the, if we stratify across the socioeconomic divides that we're seeing, are you seeing that more with women that have the means to do this versus those that are in a condition that they don't have the internet connectivity or the other equipment?
Beri Ridgeway, MD: I'm certain our view and who we're seeing as absolutely biased. I make no pretense about that. But it also perhaps gives us insight if they are unable to do a virtual visit, or if they're always doing it from outside of a local place that has free wifi, and we can use that then to reach out, to check in, to send resources that way, or refer them to the correct places. Or do you look and there's chaos going on in that house, right, and, or do they not feel safe and you need to do a better job screening for intimate partner violence. I think these are all things that you may not be clued into in a face to face visit where all of us, myself included, we've definitely tried to put on our best face, right, for the doctor.
Akhil Saklecha, MD: Yeah. I mean, I can see that. And I think, you know, we're probably early in all of this evolution of a virtual care, the improvements that can be made; we'll find probably that we'll get to a point where we can have point of care diagnostics even, so you can get blood and urine tests even at home. We're very close to that. And at that point, you can argue that most of the care could be just delivered through virtual visits; that potential.
Beri Ridgeway, MD: And I can't really talk about health disparities and what we're trying to do without our work with First Year Cleveland, because this is not a Cleveland Clinic solution, this is something that needs to be a community solution. First Year Cleveland partners University Hospitals, Metro and us, through Case Western to work for solutions for the community. It's something that we all share. And one of the aims in that is with centering and pregnancy. And this is for really any moms, but it's targeted in zip codes where we see the highest level of infant mortality. And so instead of just going to the doctor those 12 times for 15 minutes, they have visits with a cohorted group of peers who are also pregnant and about the same stage of pregnancy. So they will have a thorough lecture on say nutrition, to provide those skills, as well as peer support. And then they'll have the quick check with the provider, with the heart tones and the blood pressure. And that's been highly successful. And with COVID, we've now made that virtual, so that they still can get that type of care that's so important, and that information that's so important. Centering also is now centering in parenting. So because, as anyone who has kids knows, that's the actually when the hard work really, really starts.
William Morris, MD: Yeah, I love that idea. Kind of the shared medical appointments has been something that certainly chronic disease has broached, but certainly this episodic care it seems so logical and natural, but yet we haven't done it. And so, kudos to the innovation and the fact that it takes a community. And then actually, we should be collaborating shamelessly with all providers in the region. One question I have is, there's a lot of talk about returning to normal; but yet I'm kind of remiss to think that I don't think there is a normal, I think there's a new normal. In specifics to Tele-health, 95% of our visits were physical before COVID, then we dramatically shift, where do you see it actually falling out? What is the natural percent that can again provide the most valuable, or value to our patients that's affordable, that's accessible, but also meaningful and impactful?
Beri Ridgeway, MD: I agree with you, this is a new normal, that we're charting and we're determining right now. And we cannot return to the way that we were. I would argue that during March and April, we likely had too much virtual, which was a necessity, and that was exactly the right thing to do then, but should we maintain that? Probably not. We did the best we could in that people weren't willing, or in certain areas, we couldn't have them come in. What I did as part of the work with the virtual health was I went to each service line and I said “what makes sense for your service line?” So for example, for women's health, I said, okay, on average, 12 visits, four can be virtuals for say, 80% of our patients because the other 20% probably are high risk or don't have access. And then we went to each service line, uro-gynecology, minimally invasive gynecology, GYN oncology, and ask them those same questions. As you know your service line, what diagnoses and what can you optimally treat via Tele-health as opposed to an in person visit. And with that, then asked every Institute to do that because in some places it should be close to 75%. Diabetes care is one of them that can do a great job. Gastroenterology, also is an area that has done a great job maintaining that. Whereas other specialties are very exam based and those don't do as well. And so with all the math across different service lines and departments and institutes, we landed at about 20% virtual. My guess is that's a little bit low, but I think as our technology and our infrastructure for virtual visits with ease of camera, the platform, as well as developing service line specific support, how a medical assistant or a nurse can help do intakes, or you're just doing the top of licensed job of a physician or an APP. I think once we get into that, we'll be able to see it go a little higher, but really from 5% to 20% is massive accomplishment over three months, four months. And the other part that's going to be critical is the regulations around Tele-health and the billing and reimbursement, because that's a fear that a lot of people have is, I'm essentially doing the same amount of work, but you're going to want to reimburse me less. And so I think that in the next few months, or by the end of the year, early next year, we'll have a much better idea about that and continue to push this forward.
William Morris, MD: Yeah. And certainly, I mean from our office, we are actively involved on pushing for payment parody and also state line consistency for licensures. We see these are needless regulations that impede critical advances in the startup community, and the technology. So it's great to kind of be working on the same problem or opportunity from a clinical side, but also then from the innovation side as well.
Akhil Saklecha, MD: So maybe if we switch gear and we talk now about what we're seeing in your other hat. Which is away from women's health and more around how the Cleveland clinic and you specifically have been involved in the COVID response. Can you share some details into that?
Beri Ridgeway, MD: Absolutely. It has been an amazing experience for me and I have learned so much over the last four months, and it's so interesting to think that this really is a little over four months ago that all this happened. It seems a lifetime ago, I was tasked with initially working with the surgical wind down, because early March, there were some ideas that this pandemic was really going to happen. It was coming our way and by mid-March, we worked with the Ohio Department of Health to safely stop and postpone all non-essential cases. So these would be not urgent cases like having an appendix removed or being treated for cancer, but for people with hip pain who had planned a hip replacement, and to take those patients and postpone the cases; so that we could create a response for COVID. Number one, of course not exposing those patients, but then taking our resources like, nurses, MAs, et cetera, to other areas so that they could treat patients there. And then following that, when we realized that we at least temporarily flatten the curve and we were seeing massive, massive consequences of deferred care, we've now been reactivating, and were fully reactivated over about four weeks, towards the beginning half of June. And now we're working on coexisting with COVID, right; excelling in our clinical service to patients for both COVID and non COVID care.
William Morris, MD: So I have a question for you, Beri. Is part of the plan kind of separating these patients who are COVID positive and need to be managed in a hospital, and keeping elective cases and that surgical cases, and certainly you've addressed the deferred care crisis, is that part of a playbook or are these things that are all kind of just evolving and you're learning as you go?
Beri Ridgeway, MD: That's a great question, and our thinking on this has evolved over time. When we first started the reactivation process, we were pretty dedicated to the concept of cohorting and cohorting when possible. And so part of the surgical platform involved testing and for cases that are non-essential, meaning essentially basically elective, they need a COVID test 72 hours prior, and we're keeping those areas really free from COVID, and then cohorting, pre and postoperative patients together who are known COVID negative. And we have stuck with that plan. But when we talked about the ambulatory space, we talked about something similar, including outpatient areas where they only treat COVID patients, but what we realized is when we look at our total population, about 2% of our cares COVID care. So it's really a tiny, tiny percentage though, in our minds, it takes up probably 80%, but it's a tiny proportion of patients, and most of those services that they need can be done remotely, and the other services are not essential. For example, you don't need a skin check or a pap smear in your first 28 days of having COVID. So we've been able to defer, and rightfully so, some of that care, but for essential care, like for example, someone who has COVID and falls and fractures their arm; it doesn't make sense to have a whole set of services pulled from our patients who really need regular care to this. As well as we've done a great job as an organization, protecting our caregivers and protecting patients with our use of PPE, cleaning protocols, and so as well as the thought that we're having patients who have COVID come in with no symptoms, probably every day, just given the sheer volume of patients that we're seeing and what are asymptomatic positive rate, which is a little under a percent. So with that, we have decided to stick with what we're doing. That's been working. We've seen very, very little spread within the healthcare system, other than coworkers who spend a lot of time together. And then allowing us to maintain normal operations for all patients, and each area has a specific protocol to bring in patients who have COVID for essential care.
Akhil Saklecha, MD: The Cleveland Clinic has, as you said, is doing a lot to protect, not only the caregivers, but patients coming in, and now everyone's receiving a mask when they're coming in. But there's still a fear of patients who are at home who want to come in, but realize that, you know, they for whatever reason have this fright of catching Covid by coming to the hospital and how are you, and how is Cleveland clinic encouraging these patients or reaching out to them to come in for that important care.
Beri Ridgeway, MD: It's tough, and I completely understand this fear. When COVID first hit in those first few weeks, I, even someone who's really ingrained in the system, told my kids you better not hurt each other because I'm going to be taping you together. And we're not going anywhere near the hospital. So I completely understand this fear and especially in patients who are high risk, but it is a safe place to come. And really we have to compare it, not to nothing, it's compared to the unintended consequences of not getting that care. And so it's not saying it's COVID, or I'm perfectly fine. It's that tiny risk of going anywhere, or anyone in your family going anywhere, right? Or coming to the hospital to I'm really not doing what's right for your health and those long-term consequences. And as an organization, we've been messaging, we've sent out a number of emails, and I think our communications team has done a phenomenal job in sharing the steps that we're taking, and that we are focused on providing the right kind of care and with the right platform at the right time. So whether that's virtual visits or whether even with our preoperative, sort of checklist and what a patient has to do to schedule surgery. There used to be a number of face-to-face stops for that in person stops with pre-auth and financial, et cetera, and have now really transitioned that to frankly, a way it should be, right; easy and patient centered and all virtual.
William Morris, MD: That's exactly right. I mean, I think there is good that comes out of this. It really, really draws into focus: What is essential? What is needed? How can we break down the barriers and drive access? Cause, I could not agree more. It is incumbent on us, not just to deliver excellent care, but to make it accessible, affordable, and frankly pleasurable. And so, kudos to you. What has surprised you during this as a leader during these four months? What kind of surprises have you kind of walked home and taken away?
Beri Ridgeway, MD: I think this didn't necessarily surprised me, it just really drove this home in how many amazing, super smart people we have here. It really has opened my eyes and to, as an organization, who we have on our team and where we can go. I think the thing that also has surprised me is that it took something like this to really start talking about a patient centric model. In that, I know we have talked about this, and I think as an organization we do much better than most places, but it's still, and having patient experiences myself, it's hard to be a patient anywhere, not just here. And I think as healthcare in general, not specific to Cleveland clinic, we're really saying like, where can I meet you where you are? How can I meet you and how can we succeed as a team?
William Morris, MD: Could not agree more. Akhil, I'll give you a last word if you would so desire.
Akhil Saklecha, MD: Thank you, Will. I have to say, this conversation was enlightening. I mean, not only on the first part of our conversation around the innovation and gaps, because on that side of the house where Will and I spent a lot of our time, in finding out those clinical problems that need to be solved, especially what you've seen on the improvement with virtual health, but also the gap that remains of how we can continue to improve on the prenatal care. But also, on the second side, which is we've talked so much about the negative impact of COVID, but there's positive stuff that's coming out of it. And I think that when we can shift to the patient centric model that we've always talked about, through all the different approaches that were mentioned, there's some silver lining around all of this. And I think that's important to realize and come out of this. I have to say, I really enjoyed the conversation today with Dr. Beri Ridgeway. And Will, I'll turn it back over to you.
William Morris, MD: Well, thank you very much, Beri and Akhil. This is Health Amplified, a Cleveland Clinic podcast, intended to talk with key subject matter experts in the field of innovation, clinical care and operations. Thank you.