Communication and training are key to keeping our front line caregivers safe and effective during the COVID-19 crisis, and in the era of social distancing our guests today may have a solution that actually works.

Arup Roy-Burman, MD is the former head of the pediatric ICU at UCSF Benioff Children’s Hospital and the CEO and Founder of Elemeno Health.

Ashley Ramirez, MS, RN, CPNP-AC is a nurse practitioner specializing in pediatric ICU and a clinical specialist at Elemeno Health.

Get more info by emailing Elemeno’s peeps here and check out this video.

Hey everybody, it’s Dr. Z. Welcome to ‘The ZDoggMD Show”. Okay, there’s a huge problem right now with this COVID pandemic. And it relates to education. How do we rapidly support our frontline clinical staff? Our nurses, our doctors, our respiratory therapists, everybody in a hospital or clinic setting who’s taking care of this with education training. How do you put on and take off PPE? How do you deal with ventilated patients in the ICU? There’s a million questions and there are very few teachers who have the time now, ’cause everybody’s working, to be able to train people on the frontlines. Well, it turns out there may be, once again, a technological way we can amplify the teaching. We can make it customized for your situation while pulling in best practices from around the country that can be applied right there on the frontlines. It can save lives, not just for our patients, but actually for healthcare professionals themselves. And I found one of these bright spots right here in The Bay Area, a company called Elemeno that is doing something quite remarkable. And I have two of their peeps today as guests on the show. We’re gonna do it by zoom ’cause social distancing. And the first is Dr. Arup Roy-Burman. He is the former director of the Pediatric Intensive Care Unit at UCSF’s Benioff Children’s Hospital in San Francisco. He’s now the CEO and founder of Elemeno. And then we have Ashley Ramirez who has a million letters after her name, but she’s a pediatric nurse practitioner in practice here in The Bay Area and she’s a clinical specialist for Elemeno. Guys, welcome to the show. Let’s get our learn. Arup, maybe you can start by telling me what was it that sort of prompted you to start this company and what problem are we solving here during COVID?

– I’ve been in practice for about 20 years and in peds critical care, we took all of our call at the bedside at night. So really working hand in hand with our nurses and really understanding their pains well. And watching over that past 20 years how medical complexity just growing exponentially. So much we’re expecting our teams to be able to master. And as that pile gets bigger and bigger and bigger, you just can’t. And what that means is we get more and more practice variation. That means mistakes. Mistakes even by very hardworking, well-intentioned people. And the real driver was, so we were seeing that despite people working so hard, things were getting messed, patients were getting harmed. What could we do through technology? Technology, this stuff today, the only reason it succeeds, is it because it makes our consumer life, our home life easier. It enables us. But in healthcare that technology was just a barrier growing bigger and bigger, pushing us away from the patient. So we said, how can we bring the convenience, the consumer space into the clinical space so it could help all of us? Me, doctors, nurses like Ashley, respiratory therapists, all of us more quickly master what we need to do and do it the right way. Better care for our patients. We feel better too. And when you put that in the setting of COVID, that is just amplified.

– So I wanna say something about this because what you’re saying is, take the technology that we know and love already that actually works. So whether it’s mobile device technology, whether it’s web-based technology, it’s very different than creating a massive platform for technology and training like an EHR or something where it’s behind a million different walls and all of this. You just said, well look, this isn’t about HIPAA and that, it’s about training staff and we can do that the way staff learn, which is on their device or on a web browser quickly and effectively. And that way you reduce what you said, care variation, which is near and dear to my heart, what we ought to be using best practices and then tailoring them to the patient at hand. And so this was something that really got my attention. And during COVID when we’re trying to train people, how are you rolling this out now to institutions and what kind of things are you doing around COVID? Because I tell you, dude, it’s heartbreaking when I hear from frontline nurses in particular who tell me, Z, you don’t understand, we are terrified because no one’s told us properly how to take care of these patients, how to put our stuff on and take it off of, what’s the appropriate, they change it all the time. I haven’t looked at a ventilator in forever. Now I’m being asked to float and help and do all this stuff now. How can I get up to speed? And so that’s why this really interested me when, what are your thoughts on this?

– Sure, I’d say there’s three points that we’re trying to address. One of them is team communication. If I’m a nurse in the ED or a doctor in the ED, I’m getting the blast of multiple emails a day plus everything on a very large hospital intranet. About everything my hospital cares about. But for me, my world is the ED. That’s what matters. And you add to this mix, that media frenzy all around us, so much information overload. It’s so hard to separate signal from noise. So what we do is we can help that platoon commander, if you will, that unit manager, the ED director. These are the nuggets. Z, I want you as an ER doc to know, this is what I’ve filtered. So me as a frontline staff person, I’m seeing what is important to my environment and I’ve got a single point of truth that is curating all that information that what is constantly changing and relevant to me. So there’s team communication. The second point is training. The way that we all learn today, it’s about adult learning. It’s what we call microlearnings. Small bite-size units I consumed in the moment. It’s what I need to know right now. Put me in a classroom for an hour, 80% of what goes in this ear pops out the other. But it’s about, I need to put on my PPE now. Great, can I see that here in a video? Boom! So that’s the ideal point of care training. Or if you look at, you were bringing up that example of a ventilator. And let me pull that back a little bit more to one that’s even more common with that cross between professions. We’re used to the respiratory therapists giving the nabs, the nurse doing the nursing piece, but in this COVID situation where we’re trying to minimize exposure to people, if I’m all bundled up in PPE and I’m there with the patient, and now, Hey, I need to give a nab, let me cross-train to be able to do that too.

– Yeah.

– And I’ll give you one last piece really quick. The third piece is sharing practices. That we are all across the country tackling the same problems. There may be some little nuances about how we do something in our local facility, but it is how to put on the PPE. If it is how to set up that ventilator, how can we all come together as a community? Get out of our institutional silos. We’re doing it really well right here. Wonderful, let me grab that, approve it and do it in my facility too.

– Yeah, and that makes perfect sense. And if you look at the way the South Koreans are using technology to public health and things like that. We can do that here too. Same thing, care variation. And Ashley, I want you to weigh in on this because you are a frontline-practicing nurse. In fact, you were just last night on shift and are coming in now, sleep-deprived to do the show because you care about this. So tell me, what’s your experience with this and why did you get involved?

– And she looks great too.

– She looks great. I don’t, why do you look so bad Arup? I don’t understand, you’re in home isolation. So Ashley, tell me your thoughts on this thing and how it works to help nurses in particular.

– Yeah, I’ve been a nurse for the past 14 years in the peds ICU and NICU past five years as advanced practice working fetal medicine and in cardiology and CT surgery. So with that level my job working with the CT surgeons was, how do I get their message out? Which is a similar message that a lot of these managers and educators are dealt with or handed with. And especially in COVID, when you make a quick change in practice, how do I let the staff know? The current state of methods right now is by email or by flyers or by, if you happen to be on day shift that day during the Huddle. And to me, when I was working as a nurse practitioner, Elemeno was piloting in the peds ICU there. And so I saw the technology and I said, this is really the space that we need to be moving to. As we are saying, we need to utilize technology to help us. We just, our education budgets and classes are being cut. So therefore who does that affect? Nurses, respiratory therapists. And we’re just trying to clamor to try to get any type of information and push it out at scale. So I thought, and that’s kind of why I reached out to Arup ’cause I thought this is a space that we need to be in, especially as nurse educators, nurse managers, nurse directors.

– So what’s interesting about that is that we can use a device, quickly end up with a video update at the point of care where you’re quickly learning something without what you said, which is the flyer in the break room or the mass email that makes people wanna stab their eyes out, the overwhelm of information where you don’t know what’s important and what’s not. Or the Huddle where it’s in person. And I’ll say, in the Korean, the Hong Kong, the Singapore experience, social distancing within hospitals during COVID.

– Right.

– [Z] Right?

– We said we can’t even, that’s our only method right now is Huddles. And that’s even being separated because we can’t all cowork together. So now we’re really trying to grapple with what we’re supposed to do and how we’re sending out message, so.

– So Ashley, you guys came up with this before COVID as a solution and now it seems like it’s the perfect fit for mass, rapid, updatable and controllable education of staff during this. Have you guys rolled it out in different institutions now?

– Yeah, well, we definitely have clients in place across the nation. And so they’re immediately the first clients that we started to work with, trying to say, how can we help? What can we start creating for you? How do we push this information out? So we quickly, I’ve worked closely with The Children’s Hospital New Orleans, which right now they’re unfortunately a hotspot and they’re in a huge crisis right now. So we quickly were able to build out a portal for them as we coin it as a navigator, but it’s just a streamlined way to get all of their information, whether it’s from the CEO, from the managers, and then down to the practice variations that they’re require from the respiratory therapist, a hands-on training. We’ve been unique way to be able to kind of organize that information. So when you’re in the unit and you need that information quickly, you can just grab it. You can click onto it, you can look at pictures. Our therapists over there well versed so they can spit out short videos just from their iPhone, send it to us, we mash it together and we’re able to put it up within a day, so.

– So let, yeah, let me ask about that. So let’s say I’m a nurse manager and I’ve just gotten word from the infectious Infection Control Department that Hey, there’s a new way that we can use chlorhexadine or whatever it is to sterilize X, Y, or Z. Okay, I need to get this out right now. I get on my phone, I go, okay everybody, this is what we need to do. We just learned this. This is the new piece of information, blah. Send it to to Elemeno. Elemeno then processes it and sends it out as a thing via the app. So whether they’re looking on the app or whether they’re on a web browser, they can quickly get an update.

– [Ashley] Yeah.

– Did I do that justice? Is that how that works?

– Yeah, we definitely, go ahead Arup

– what I would add to that is that for some of our more advanced users, if they want the keys themselves, that they can drive, that there’s functionality they can do themselves. And that would be kind of the classic example for us is at the Emergency Department at UCSF on Parnassus. It’s ground zero for us here in California for that emergency response to COVID. They were on the leading edge. They had deployed Elemeno last year and January 27th is the first time they started putting code-specific information into the ED support at Parnassus. That has just grown every day, multiple times a day, additional updates to it. People have a point of truth. And what’s been beautiful is that our leaders there, Dr. Jean Noble, who is the Director of Disaster Preparedness and Dr. Maria Raven, vice-chair of the department and chief of the ED, they have both advocated for sharing those practices with other hospitals in need. So we took that and last weekend, Sonoma Valley Hospital was asking for help. We connected with them and within 12 hours of that initial call, we were up and live and deployed in their hospital with a blend of shared content from UCSF’s ED plus their own content. And I will add, as we’ve been doing this around the country, announced just this morning, El Camino Hospital System in Mountain View and Los Gatos, they gave the go-ahead, we wanna do this. We are proceeding on a verbal agreement alone. And we will be live today in both hospitals, across all of their inpatient units, plus importantly, environmental services, because people gotta be able to keep the place clean after such patients pass through.

– Okay, I gotta interrupt you for a second. Okay, there’s so much crazy awesome stuff here and this is why I agreed to do this because, and I get pitched a lot of dumb apps, Arup. A lot, a lot of people. I get emails every day like, check up my app to solve COVID. And I’m like, that’s the dumbest thing I’ve ever seen. But I respond, thank you for working on this. We’re swamped. But when I heard what you were doing, it just clicked. And there’s several things here. The fact that you can take a center of excellence like UCSF and scale their knowledge out into the world, whether it’s rural hospital or a community hospital or another academic center, is tremendous. The fact that you can get the thing live in a day goes to show that you’ve kept it simple. You’ve kept it fricking simple. It’s not behind a billion firewalls and crushed by HIPAA and all that because it doesn’t need to be, it’s flexible and usable at the point of care, very fast, which is another huge thing. And the third thing is, physician and nurse leadership means it’s not gonna suck. It’s not gonna be technology built by tech nerds for tech nerds. It’s actually gonna work. And I was hoping you could show us exactly because we might be able to screen-share here. And I wonder if that was a good time to show me that.

– Let me show you something just we’ll do a quick little preview, and jump in here. All right, so what you’re looking at over here is the application as it would look on a phone. You can favorite your own look, customize yourself, your leadership can assign content to you. We can make distribution fun through gamified challenges. Day shift or night shift, medical ICU and surgical ICU. And importantly, we can drive recognition. Because especially at a time where morale is tough and we’re distancing ourselves socially, how can we at least digitally thank each other for the hard work we’re doing every day? So if I jump out on this one, if we’re looking at on a desktop version, here’s your team card and how easy searches, I can come in here and I can say, Search PPE. If I do that, what do I get? You see here anything that’s tagged to PPE, starting with the name, here’s my PPE resources, jump in, notes on this. How do I wanna put on or put off, tick off PPE? I can jump in in here and here we go, quick two-minute video on what I need to do to put this on. So I can find things in that manner. I can also come in, if I’m from my homepage, go straight into the navigator. And if I’m in the navigator here, it may be, you know what? I wanna dig into how to swab a patient, what? Great, it’s text plus pictures, things that I can find right in the palm of my hand.

– Mm-hmm.

– What I need in the moment so that I can do it right. That kind of just-in-time coaching, if you will.

– And what I love about it is that we can add in the supplies that your hospital actually have ’cause a lot of the generic Elsevier and all that stuff, it’s just, you won’t have the same type of supplies or equipment. So what I like about this is we’re really customizing it to your hospital, your unit, so that you can really close that last gap to deliver the same uniform care.

– Yeah, that makes a lot of sense. And I see it’s branded with your institution and all that, which is nice because it then customized, but at the same time you can scale across institutions, shared learning.

– [Arup] Yeah.

– What I loved about that is that you have right there, like you said, how do you do a swab, right? How do you properly get back far enough? And when you need it, like, man, I’ve forgotten how to do this. Pop it up right there or on your workstation that you’re charting on anyways. And again, it allows us to keep distance. We’re gonna have people on the show this week that are gonna talk about how they’re training frontline staff. Now this is a way to scale their ability to train, just like our show is a way to scale a message like yours, right? So what you’re doing is actually very aligned actually what we do on our platform. So I think that’s another reason I think there was an obvious kinship there. Ashley, what’s been the response from frontline nurses because any more information that we’re fed, especially if it comes from above tends to be met with resistance. Do you find that your platform is met with resistance or do the frontline nurses embrace it more?

– No, I think they do. I think we have a different mixed generation in nursing, I would say. So definitely it’s been slower adopted in some people who are used to their cookbooks, or their folder, looking at it by hands or by bulletin boards. But we’re seeing actually an uptake. Once they get fully introduced, they see the technology that it’s easy friction and then they adopt it and they are looking at things. Of course the millennials or post-millennials, they love technology. And so once they go in, it’s easy to just search and find the stuff that you need. So we definitely see that they’re happy. But mostly what I’m happy about too is the educators and the directors, it provides the space to be able to communicate effectively to all of their frontline. And I will say, and my clients in New Orleans and across the board, the most viewed content pieces are the weekly updates. So that to me tells me staff want, they want to hear what the managers and the directors are telling them. So I think it’s a cool technology and I love it.

– That.

– Z, I wanna add something on there. Are you familiar with the terms old power and new power?

– I’m not, although it sounds vaguely awesome, comic book-level awesome.

– So, let me quickly talk about what that means and how that relates here. So old power is that typical hierarchy from the top down. Going back to the middle ages, you’ve got the king, you’ve got the nobility and then you’ve got the peasants. Everything just flows downhill one way. And old power has been the structure of corporate America for years. It’s been the structure in hospital for years, where the frontline staff are passive consumers of information and orders but don’t necessarily feel like they are heard. So the idea of new power is what companies like your Google and your Facebook are doing. It’s really listening to the user. What is it that you want? And allowing the user to be able to rate content, to be able to share content, to be able to create content, right? And so if we bring that into this hospital setting, what’s been for me really cool to see is that you’ve got that rockstar nurse who knows how to do the sternal wound dressing. You’ve got that nurse who knows how to prime the dialysis circuit. She is your rockstar that every manager says, Oh, go see how Ashley does it. Or go see how Stephanie does it. In this case, we’re able to take those rockstars, they can capture it on here and then we compact and we put the text overlays, go into the system, their manager approves it. And now your frontline rockstars are being elevated as teachers in their community as well.

– This makes a lot of sense. Now I wanna get into the elephant in the room, which is always the case with technology. But if it doesn’t make my hospital money, then we’re not gonna get it. Or an IT guy going, well, if we can’t put it behind our firewall and control every click and clack, then my whole reason for existence no longer exists and so I can’t justify my salary or the thousands of meetings I force people to go through every day. Are you seeing this or are you seeing a more nimble response from people who are seeing, due to frontline pressure, people wanting this? Like you said, a new power structure, which of course threatens old hierarchies a little bit, but we know that that’s the future. We know that’s where it’s gonna be. We know that’s the future of organizational dynamics in organizations too. That that the top-down management is no longer gonna work. And actually COVID may wash that old model away. And that’s one of the exciting few silver linings in all this. But anyways, can you speak to any of that?

– Yeah, so first off on that idea of, can we show that it saves money? And we’ve got data here that shows we can cut costs on training, because you’re not pulling people off the line. You can help them to digest that in the moment. And our educators will tell you they’re about 25% more efficiency. So we can show that labor savings there. On the other side, we can also show savings in outcomes. We’ve got studies that we have published and presented nationally showing that we’ve been able to decrease care variability and reduce hospital-acquired infections.

– [Z] Mm-hmm.

– So that’s the money-saving there too. The bigger barrier is, this is a different way of learning and teaching.

– [Mm-Hmm.

– It’s something different. And when we think about healthcare, we do that oath as doctors, first do no harm. And for the healthcare institution, it’s about, well, I don’t wanna go first with making change. I wanna see something proven out by somebody else. And that’s why I think as healthcare, as an industry, we’re such a late adopter when it comes to the technologies that have succeeded in so many other industries.

– Yeah.

– So with that in mind, when we come to hospitals, the question is, for them, is it worth it for us to make that change? Is the pain of change, how does that compare to the pain of staying the same? Right? And for us, with this pain of change, we tell them, look, it’s easy. They don’t believe it until they start seeing other people doing it. Just like you saw here with these series of hospitals hearing, Oh, one hospital, that is so easy, I wanna go next. And when we come to the idea of the IT leadership, there are different personas out there. I would say there are the personas that are exactly what you said, I wanna keep everything behind the firewall so that I am able to control it, to be able to control the data. The downside is that your staff, like say Ashley before she comes in for her shift, she has no idea what’s on the other side of that wall, what she’s gonna walk into. If you can allow that data to flow, we have no protected health information. If you can allow that information to flow transparently to people at home, they can psychologically prepare themselves for what is going to be a scary and strenuous shift. Let them understand that more as they come in, let them prep. It’s like if you’re sending soldiers out to battle, you just throw them on the frontline? Or do you prep them before they go in? Right? And so there is that block that some IT leaders have had. There are other IT leaders, like I talked about El Camino. How about we mentioned Deb Muro who is their CIO? Deb’s take was, you know what? We do need to get this information. We do need you to support us if we do need to commute. And I love how this is so easy to do, let’s do this. And then I dug into it a bit after our conversation. And she said, Oh yeah, I used to be a nurse. Uh-huh.

– Bingo. Clinical relevance.

– You have empathy for what is happening on the frontlines. And that is the biggest missing piece that we see. When we talk to different hospitals, those where leadership has empathy for the frontlines, where they are actually talking to their frontlines or the frontlines can talk to them, there the dialogue moves very quick. Those where there’s layers behind, we have people on the frontlines who are hurting about, I wanna do this but I just can’t get it up the ladder.

– Man, that’s the perfect transition into a call to action here because I was talking to Eric Topol, Dr. Eric Topol about this and he said, we are the only industry where we have given up our leadership to people that have nothing to do with our industry, that have never touched a patient, that have no clinical experience. We’re the only industry that allows that to happen. And it’s got to change. And so one thing we can do is, let’s have a call-to-action here for the If you are interested in this kind of thing for training, we’ll send you to a website link right? That you’re gonna give us, that we’ll put in the description and I’ll put it up on the video as well if I can. Although I wanna get this out quickly hopefully because I want people to understand that this is time-sensitive with COVID and you guys can spin up training quickly. That’s why we’re doing this now. And talk to your leadership, your clinical leadership about this as quickly as you can because this is a way to scale some of the best teaching we have, our best practices in your organization and outside of your organization during this crucial time when there aren’t enough people, there isn’t enough support and everybody on the frontlines is suffering. Here’s a way to relieve at least a little bit that suffering and improve the care for our patients and keep us safe at the same time. So I, first of all, thank you as a fellow UCFS person for doing this with your clinical training. And Ashley for coming on the show. After working a shift. Come on, it’s typical nurse, right? By the way, you’re working on your DNP now, right?

– Yeah, I got accepted over at Johns Hopkins and I’m gonna be doing a dual DNP/MBA.

– What a gunner? Really? You’re gonna do a dual MBA/DNP? So you’re basically gonna be running a health system at some point and I’m gonna have to kiss your butt and do all the Just so I can make sure.

– No, you won’t have to because she’s gonna have empathy for what’s going on.

– No, yeah.

– Right here.

– Got it.

– I love it. Guys, thanks a million for being on the show. Thanks for doing what you’re doing. I’m gonna share all your links. And thanks for being a part of this movement. And guys out there, stay safe during this. Do me a favor, subscribe on YouTube if you haven’t already. We’re gonna have all the links to Elemeno available for you to check out. Please check it out, leave us feedback, leave comments, share with anyone who’ll listen. And stay safe during this time. We’re all in this together, we’re gonna get through this together, but we’re gonna have to look at every bright spot we can, learn what we can and make it happen. Ashley, thank you.

– Thank you.

– Arup. Thank you my brother.

– Thank you. And thank you to all of those frontline heroes out there.

– Yeah.

– As you’re making the difference for all of us across the nation.

– Listen to this guy. Listen to what he’s saying, especially you leaders and government. Listen to what he’s saying. All right guys, I love you, we out.