Dan:
Arup, thanks for joining us.

Arup: 
Thanks Dan, pleasure to be here.

Dan:
Great. So Arup, tell us about you, what's your background and how did you get into starting Elemeno Health?

Arup:
I'm a peds intensivist, practiced for about 20 years, that took me between Stanford, UCSF, Children's Oakland and the Kaiser system. I went into healthcare thinking, "Okay, I'm a doctor and I need to figure out how to do everything so that I can take the best care of my patients." And kind of embarrassed to say that it took me a couple of years to figure out, it really didn't matter how much I knew or what I said if my team couldn't execute on it. In peds critical care, what's interesting about our specialty is that most of us have been taking all of our call in house. So, days, nights, and weekends, and the ICU being very busy hands on environment, we're really in the trenches with the nurses.

Arup:
Over those past 20 years, watch that rapid rise of healthcare complexity. So many more pathways, drugs, devices, procedures that our team needed to master, but it was no longer humanly possible given the sheer volume. What we saw with that was the rise of practice deviation, more and more people doing things differently, and the end result of that was errors. Across this country even in the best hospitals, there's patients who die preventable deaths, mistakes made by hardworking well-intentioned staff who simply couldn't pull the information they needed when they needed it. Then I go sit in these, what we call RCAs, Root Cause Analysis, in these meetings after major events. I'd say 90, 95% of the time at the end of the day, we'd say, "You know what? We knew this as an institution, but our frontline staff had forgotten." And now after the fact, in a reactive manner, we'd go to them and try to teach them up, but it was too late.

Arup:
So the question was, how can we be proactive rather than reactive? The question was, is being here in the Bay Area over those 20 years saw the rise of technology? So kind of like the great enabler for us, and in our consumer lives it made it so much easier to manage our families, manage the kids' sports, manage my personal life, manage my shopping, all these things that they needed to do and made it easier. But in healthcare, the technology that we had that was coming to us was really the monster of the EHR, and it was providing this growing barrier. It made it harder in a way to deliver care, made it more and more in personal. The measures of the EHR to drive safety were really all about a forced function, click this, click, this, click this, so to assure that I will only do that, and it also kind of dehumanized it for me.

Arup:
And so it was ... how could we actually use tech as an enabler as it is in the consumer space for our front lines, so that we can all be our better selves, and we can all be empowered to do the right thing and pull the information we need and the support when we needed it.

Dan:
That's a great story. I've been speaking all over the country about something similar, which is, care is so complex now, it's impossible to memorize. In the past [inaudible 00:05:40] medical schools, nursing schools, clinical training programs were all about memorization of the data. And could you recall what we taught you either on the chalkboard or in the book, and now it's becoming more how do you access information? So, Elemeno is definitely in that vein of just in time learning and accessing information rather than having to memorize all of the things that you need to know. I'm interested to understand what was that moment where you're like, "I'm going to leave the bedside full time and actually turn this into a company?"

Arup:
I guess, kind of following and maybe the arc of my career, I had been in academic medicine at UCSF and I moved from there to Children's Oakland, which was the freestanding children's hospital at that time, focused really on clinical medicine, and I was interested in driving our quality, driving patient care. I got recruited back in 2011 to UCSF to lead their peds ICU and to lead the development of their transport program. I had some misgivings about it that I really liked having to focus on patient care, and there's some wonderful work going on at UCSF with academia. Pretty much all the faculty are doing something from research, but I felt that some ways that would be a distraction for me, I just wanted that focus on just making care better and making our hospital better.

Arup:
With that, they actually said, "You know what? Actually, we're going to be opening a new hospital at Mission Bay, we want you to help us drive clinical quality to help us grow our business, and that will be your focus. That's what you will be benchmarked against." So I was like, "Oh great, that's the area that I really want to put my energy." The other piece that came with that was, Salesforce was supporting UCSF. I started asking my colleagues, "Do you guys know what Salesforce does? Well, what do they actually do?" Some people knew that. "Okay, they're about CRM." But they were like, "What is CRM?" "I don't know." Well, the idea of customer relationship management and how you could use the cloud to be able to deliver information or services to your customers to track their engagement, to understand your gaps so that you can turn around and better serve them.

Arup:
And so why don't we use that same idea, not just for transport with our external businesses, but let's use that internally to look at our nursing staff and our frontlines as our customers. If we start looking at how we can inform and support those customers and how we can create a feedback loop to understand what their needs are and service those needs, then we will have happier customers and staff, and what that will mean for us is that we're going to have a better product, i.e, a better patient experience in a patient journey. So, that's what convinced me that, "Hey, here's an opportunity at UCSF with partnering with technology that's easy to use, and let's apply that in healthcare and see what we can learn."

Dan:
Yeah, I love that story. And we've skirted around it a little bit, but can you give us just a real concise overview of what Elemeno does and is?

Arup:
Sure. So, for Elemeno, you can think of this as point of care microlearning and that as a service, because if we're talking to an audience here, there's lot of nurses and nurse leaders. I think everybody can relate to the idea that in my unit, my ICU or in my ED, how do we keep our staff current with all this information that's coming through and all the changes? The way we do it is, we go and send emails, we have staff meetings for an hour and everything goes in one ear and out the other, we put stickers up above the door in the med room. We put things in binders, and we put flyers above the toilet in the staff rest rooms.

Dan:
And Manila folders and flyers in the bathroom. That's like the core of nursing education right there.

Arup:
Exactly, exactly. That's the way we have done it for years, these analog processes. So, why can't we take the nuggets out of that and transform that into bite size pieces of learning? That's what's microlearning is, it's bite size pieces of learning, which can be consumed just in time when and where you need it, contextual learning. I'm doing this dressing change, how do I pull up quickly the video on my desktop, or maybe my mobile device? And how do I set up into it? Or I'm having to make a decision on what chronic pain medications I should use in this opioid addicted patient? Well, somewhere out there my organization's got a flow diagram that is the size of a poster that nobody can fit in their pocket. Well, how do I transform that and make it something that just walks me through step by step in the palm of my hand?

Dan:
Yeah.

Arup:
So, if you think of that use case, and let's use that in the world of the nurse educator. So, the nurse educator, she or he has spent their career being a nurse and learning how to do nursing practices. And clearly they've got skill and they're doing this well if they've risen to this point of being a nurse educator or clinical nurse specialist. But you think of that word nurse educator, or that term nurse educator, how much time have they spent being trained in education? Some of these people have been practicing as a nurse for 10, 15 years, now your nurse educator, and it's like, "Oh, well, let me see how I should educate." What do they fall back to? They fall back to what they learned in elementary school and in high school, let's use posters, let's use flyers. Nobody's give them the power of technology.

Arup:
So what we aim to do is for that nurse educator, you know your subject matter, you give us a content you want to drive, it is our job as a service to transform that into these digestible bite sized chunks, and it is our job to electronically push this out to all of the people that you want to push it to. So, we help you there to be that educator, and on the flip side for the nurse, we give you a simple resource that's at your fingertips that you can pull in context 24/7 when you need it to support you when it's most important.

Dan:
That's a great example of it. I'm just thinking back to when I was a system director of nursing education at a large academic medical center, and I walked in, and one of my first charges was around having to do orientation redesign. I walked in and went through most of orientation, and it was about two weeks of lecture and PowerPoint, and literally down to how do you start an IV on a PowerPoint? When these are not to new grad nurses, these are to nurses that have practiced for 20 years or so. Once they checked off, they were able to check off that they did that PowerPoint and they went and they programmed that pump that one time in orientation. That's when we'd allow them to go practice on the unit.

Dan:
I just kept thinking like, "How backwards is this? They're going to forget everything they learned. Number one, because it's passive learning and they're probably multitasking or answering emails or whatever they're doing on the side. But number two, it's just not effective, this isn't the time they need that information. They need it when they need to use it on the unit when they're practicing."

Arup:
Absolutely.

Dan:
Yeah. I wish Elemeno was around during that time because I would have adopted it right away but-

Arup:
Well, it's now.

Dan:
It's here. It's here now I know, I know, and we're talking with that same institution. Its got funny, but yeah, it's definitely needed and it's that access to information, and it's something I talk about all the time. One thing I'd love to get your thoughts on, I recently spoke at a national conference and one of the things I brought up was that, there's these technologies like Elemeno and others that put information, whether it's EHR information or education, right, in the clinician's hand, but then there's policies on the hospital side of like, "Well, you can't bring your phone to the nurses station or you can't have it out during clinical care." Do you run into that as you go to these hospitals and see what their policies are, are the policies of the hospital actually restricting the implementation of these new innovations and disruptions of practice?

Arup:
When we think about healthcare, I think about it as a physician. When I started my career, the oath is there, right? First do no harm, and what that means is, nobody wants to do something that others haven't done before. So there's this resistance to change, so this is the way that we've always done it. This is the way I learned it, and this is the way that everybody should do it. When we look at the mobile devices, for example, most of our clients started out with either a no mobile device policy or a very restricted mobile device policy. A lot of our early proof points we were able to, in-driving practice consistency and reducing errors, we had to do that, and we successfully did it with desktop only deployments.

Arup:
But there's then a pull within the organization. We look at ... in pretty much any other industry, people have access to their personal devices all the time. It's been such an important piece of allowing each of ourselves to connect with, especially, our families 24/7. When we think about our nurses, nurses as a specialty is a very collaborative specialty, is people who are always working in teams. People who tend to be pretty social to begin with. And so many of them have families. The idea of coming into a shift and having no access to your device over eight to 12 hours, that's a tough, tough battle to fight.

Arup:
What's happened is that, historically there hasn't been a good reason in the workplace to be using a mobile device, but as we've seen in multiple clients of ours, when they've started out desktop and the chief nursing officer has seen now the value of this just-in-time support approach, many of them have said, "Hey, you know what? We're actually changing our mobile policy. We want you to be able to access this by mobile device, whether it's your personal device or our proprietary hospital device." But we see the benefits of having the support right at the point of care, to help you to do the right thing. Because we know that the more friction there is, the more likely our staff are going to wing it, because if they can't pull that information right then when they're busy, they won't.

Arup:
I'll tie one other piece there, a lot is about perception, and I think many have focused on the idea that, "I'm a patient and I see a nurse on a mobile device, she's distracted and she's not focused on me." But we have had many patients as well as staff tell us, "You know what, when I tell the patient in his room, I'm going to be accessing your port today, and we've got a best practice video here that I'm just taking a quick look at before I do that, to make sure I do it the right way." Many patients have commented back to us that it is so reassuring, because now I know that they have a gold standard that they can refer to and I can even encourage them to look at the gold standard as opposed for me to have to deal with the practice variability from one person to another.

Dan:
Now that's a great point, and you mentioned a couple things that are interesting. One, you're disrupting the policies, which is usually like a 24 month change process in healthcare, usually, which is super good. We need to get rid of that because we need access to information. You also mentioned the social elements of the platform. I'd love to hear more about how you're using gamification and social elements to actually get this information to the right people at the right time.

Arup:
Lets use an example in our hospital, we see our staff living in, if you will, or working in these kind of concentric rings of families. My closest family is going to be the shift that I'm working on in my unit. So, say it's day shift in the ICU, my next round of relatives is night shift in the ICU. Then after that, it's outside of my ICU is now it's my institution. So what I care about most is what my immediate circle of friends, my immediate family thinks of me and this I want to be able to watch as closely as well.

Arup:
So from a gamification standpoint, if there are initiatives to be pushed out for broad adoption, we can play on some of the natural rivalries of how day shift wants to be better than night shift, or the medical ICU wants to be better than the surgical ICU, or surgery wants to be better than medicine. These rivalries already exist, and when we are pushing a piece of content that's important and nurses starts seeing that, "Oh, you know what? On day shift, hey, here are the 20 of us that have engaged and here's the 10 who haven't." I can then be saying, "Hey Dan, you know if you did this too, our unit's going to look better, we're going to get more points or we're going to have a higher percentage of us are going to participate and we're going to look better than that surgical ICU.

Arup:
So we changed the dynamic from mommy and daddy and leadership telling you what to do to really peer to peer understanding, "Hey, this is important." And we start telling each other, this is important, can you do this too? So that's the way that we've leveraged gamification to really to be able to drive, if you will, peer accountability and drive that kind of team engagement. There is also another social piece that we have driven in the app, and that is with recognition. We feel, for the vast majority of our caregivers, the reason that we come to work are few, if you will, is gratitude. As you know when the patient tells you, "Thank you." It really makes your day, because I came in here to medicine too, to help people.

Arup:
In this increasingly bureaucratic and EHR heavy workplace, we've been distanced more and more from the patient. I think it was journals of internal medicine or one of the journals had shown not too long ago, that medical residents are spending two hours on electronics for every one hour that they have of face-to-face. So we need to make that face-to-face time really valuable. While there's the face-to-face with the patient, there's also the face-to-face with your team. When a nurse tells a nurse, thank you or a manager tells the staff, thank you. Or a doctor tells one of their peers or team members, thank you. That's great. Those thank you's are happening by voice in isolation, in many units they happen on a card that gets posted on the team break room, which is better because now some people can see it or what we do in Elemeno is we drive that gratitude within the app, within your team.

Arup:
So your team can see, "Hey Dan, thanks to Arup for coming on this podcast today." And the other team members can see that. And it's like, "Hey, you know what? Maybe I want to find something that I can talk about that I can get on Dan's podcast too, because it'd be a behavior that I want to emulate. Those are shared within your family, and it's from an organizational standpoint, you can start looking at what is my engagement of my teams working with each other and thanking each other in each unit and use that data to determine which are the units that need more help with engagement.

Dan:
That's a great feature to have, because one of my colleagues in the PhD program in innovation did her study on how nurses use their social networks to find evidence based practice, and she found basically it's peer to peer. So the more you can leverage what they're already doing and actually back it up with evidence and best learnings and things that's going to be key because you're not changing their workflow or their social contracts, they are just enhancing them with the technology. I want to bring us over to something that Elemeno is working on that's in the news now, as we're recording this, which is the coronavirus outbreak, we were talking earlier before we started recording about how Elemeno is actually able to deliver some content in the frontline just in time as these things are breaking. Can you talk a little bit about what's going on there?

Arup:
The challenge, if you will, with coronavirus is that there is so much information flowing and it is flowing so fast, right? That you've got information that is coming at the national level from CDC and other national agencies coming at the state level from the Department of Health and the county level on how you should be reporting. And of course then, within your own hospital, how one should be screening patients, isolating the patients. How do you keep your own staff safe with appropriate use of PPE, how do you prevent spread to an exposure to other patients, and how do you make sure that you are reporting things appropriately to the appropriate government agencies. These practices are changing all the time. What most hospitals are doing are putting information up on a website that somebody needs to go and find, or they are putting it in flyers and emails, the same old analog processes.

Arup:
So, one of our clients, a major university emergency department, they had already been using Elemeno to be able to keep their staff aligned with high risk low frequency practices from active shooters to other disasters. And when coronavirus hit, they said, "Hey, this is our go-to, I just need my ED leadership team to be the filter, if you will, for what are these different practices that are coming in, changes that are coming in from national, regional and hospital." We then turned that around same day in Elemeno, so that the frontline staff, whether they are working days, nights, or weekends, they have one place to go to, to find the information that is exactly what they need to do in their hospital and aligned with what they need to do for county, state and national.

Dan:
I love that, because now you've created the contextual awareness of all this data feed into what they have to do today through the lens of the organization which they work, the experts and the care population or patient population that they see. So it actually eliminates rumors and in a complex systems world, when there's an absence of information people make it up. So if you can eliminate the making up of information to actually give them a single source, you're actually going to improve practice. So I think that's just an amazing use case in a story that just shows the power of a frontline just in time education system like Elemeno. So I love what you're doing there.

Dan:
Let's wrap this up and I'd love to get your idea on what the future holds for care. So, what are some of those changes you see that are going to be most impactful for the frontline care teams in the next few years? We have the just-in-time information piece of Elemeno, what are some other things that you think are coming down the pike that their frontline nurses and physicians should be aware of, and also nurse leaders should be scanning the horizon for?

Arup:
Let me frame this at a high level in thinking about the concepts of old power versus new power. Old power, new power is a model of the old way of doing things, the new way of doing things. So, old power stems from back in the middle ages when we had our King and the noblemen and the peasants and the hierarchical structure.

Dan:
You mean like healthcare?

Arup:
Exactly, where we have a chancellor and then we've got the CEO and then we've got the director ... Exactly.

Dan:
Yeah.

Arup:
Healthcare embodies old power. And in old power, information flows from the top to the bottom. The people on the bottom are simply passive consumers of information. It's just you tell me what to do, I listen and that's it. You can imagine the engagement there, it's not great and the satisfaction is not great either. New power is the model that so many of the successful companies of today are applying, whether you're a Google, you're a Facebook, you're LinkedIn, what you're doing there is you are taking your users, your consumers and those frontlines, and you are transforming them. So that not only are they consuming content, they are rating content, they are sharing content, they are even producing content.

Arup:
So for them, it's like, "Hey, now I have a way that the organization can listen to me, can hear what my pains are, can hear what my needs are and actually I'll use the contributions that I make." I'm sure in every institution in this country, every healthcare institution, we've got frontline staff who are rock stars. You know that nurse Cindy can place an NG tube better than anybody. You know that nurse Susan can prime that CRT circuit perfectly every time. These are the people that managers are telling their other staff, "Hey, go learn from Susie, go learn from Debbie, go learn from Carol." That how can we take what they do and help them to package that and contribute to the system. Now you're taking them and you are raising them up, you're allowing those rock stars and the frontlines to be contributing to the ecosystem, to share with their peers. And that takes that new power engagement of your team.

Arup:
So that's one idea within the organization that I think is important. What I'm getting to there is that the 21st century hospitals must listen to their frontline staff. It is not just when they do something wrong, recognize what they do something right, and help to celebrate that and help them to share that. To take that sharing one step further, what I want to say for the future for us, it's about how do we de-silo our healthcare institutions? For so long, we have worked in saying that here's the information of the practices in our house and they are locked into my house. Then the other house next door, they're doing things their way. But we have had historically this underground economy, if you will, where one ICU manager meets another ICU manager in some conference across the country, and then they ask, "How do you do this? Or how do you do that?" And maybe they share a piece of paper, they share an email.

Arup:
But how can you help to really get them to share their operationalized solutions? Their granular practices more readily with each other. We see this already happening with national organizations like Solutions for Patient Safety, which has said, "All of our members are committed to sharing practices with one another." So I think that's a lot of, if you will, the future of healthcare, how can technology and how can attitudes, if you will, start to allow us to listen to the frontlines, celebrate those stars, and then start to share our knowledge with one another.

Dan:
That's really aligned with my vision of the future of healthcare as well, and what we're doing here at Trusted, which is giving the power back to the nurses to make their professional practice their professionals associations, less reliant on the gray data behind the scenes. So, I love how you frame that with the old power versus new power, that's a theme that I've had for a long time. So that's why we're friends here Arup, because we see eye to eye on some of these disruptions that need to happen in healthcare. Where can we find you? Where can we find Elemeno? Where can we get more information about you and the great work that you're doing at Elemeno?

Arup:
You can always link to us through our website, www.elemeno E-L-E-M-E-N-O health.com. That stands for our core values L to elevate quality M to empower the front lines with knowledge and N to engage us as interprofessional teams. You can also email at info@elemenohealth.com. And I'd love to let your audience know that every hospital and healthcare institution that's using Elemeno is very happy. If you're engaged in dialogue with us, these clients are more than happy to speak directly with you as well.

Dan:
Love it. I know you're on social media as well, and just really appreciate you and bringing your insights and talking about what disruptions we have at the frontlines of care, especially around standardizing it and getting the right information to the right person at the right time. I think it's exactly what healthcare needs now, and hopefully we'll end up reducing that 17 years of evidence to bedside gap we have. So, really appreciate you being on the podcast and look forward to seeing more from Elemeno.

Arup:
Thanks a lot, Dan. Appreciate it.

Dan:
Thank you so much for tuning into The Handoff. If you like what you heard today, please consider writing us a review on iTunes or wherever you listen the podcasts. This is Dr. Nurse Dan. See you next time.