Hello, everyone, and welcome to the Becker's Healthcare
Podcast. I'm Scott King. Thrilled today to be
joined by doctor Ryan Rivera, medical director and
clinical assistant professor
over at Stanford Health Care. Doctor Rivera, how
are you doing today? I'm doing alright. Thanks
for having me. Of course. Thanks so much
for joining us. We have a lot of
big topics and and trends in health care
to get to. But before we get to
the questions, I was wondering if you could
please tell us a little bit about your
background.
Sure. Yeah. Yeah. So, you know, as you
stated, I'm an emergency medicine doc. I'm the
medical director of the adult emergency department over
here at Stanford. But I think maybe worth
noting that I've, my whole career, I've kind
of straddled a a few different spaces. So,
you know, came up as a resident at
Stanford, did administrative fellowship here, and obviously continued
on in, traditional health care operations. Got a
master's in public health focused on administration as
well.
But also have spent a lot of time
in the tech industry. I I used to
be a program manager over at Google. I've
been part of a number of,
health tech start up companies along the way.
And then,
currently, I'm also the medical director for digital
health for acute care here at Stanford Health
Care and also run kind of our industry
partnership program as well.
So we've kind of viewed things through both
lenses. How can we use traditional operations
to expedite throughput and improve care? And then
also how can we leverage technology, especially in
the current environment to do those things better.
When you see how emerging tech has kinda
taken health care by storm, are you really
glad that you you spent some time in
that space before you got to where you
are now?
Yeah. Absolutely. I mean, every
one of the things I like about technology
is,
it's it always seems like you're just right
there on the bleeding edge of some really
cool stuff. And so, you know, right now,
it's it's AI,
obviously, but, you know, previous to that, it
was telemedicine. And, you know, previous to that,
it was clinical informatics. And so,
they
I think it was exciting then, but it's
even more exciting now.
Yeah. A 100%. We're always we're always waiting
for that new that new shiny object. It's
always about to come, and and we do
get it. And then there's another one.
What
opportunities and headwinds do you have your eye
on right now in health care?
Yeah. You know, I mean, I think definitely
the the you know, from my position in
the emergency department, one of the biggest headwinds
is this kind of national crisis we're having
around boarding and capacity.
We experienced it at Stanford, but we're not
the only ones. I mean, emergency departments that
are half filled, sometimes
three quarters filled with,
you know, overflow
boarding patients,
who are, you know, admitted at the hospital.
And, you know, the
the associated problem of just inpatient hospitals not
having enough space,
you know, either either because they lack the
the physical
plant to do it or because they don't
have sufficient staffing to utilize their beds.
You know, I I think the other thing
that we're grappling with at Stanford, and I
know we're not the only ones, is, you
know, the acuity,
that we see is rising.
Some of that is due probably to an
aging population.
Some of it is, you know, a little
bit of a mystery. It'd be interesting to
see, you know, from a population health perspective
when we look back on this era post
COVID and study it, you know, why acuity
seems to be rising in EDs across the
country. But it it it's definitely true for
us, and I know it's true for others.
So how do you deal with that? More
people coming in the door,
those people are sicker than they've ever been,
and you have to manage that with fewer
beds than you've, you know, than you're used
to having to care for that population.
Yeah. And and you mentioned, you know, kinda
needing more staff
influx of patients.
So, you know, a lot of times that's
acquired through growth, obviously. So how are you
thinking about growth and adding value to your
your organization?
Yeah. It's interesting. You know, in the emergency
department, we're one of the only,
you know, clinical groups that really doesn't wanna
grow too much. I think I think we
would prefer if there were fewer patients coming
in the door or at least if the
patient's coming in the door,
you know, we're, we're ones who,
you know, truly needed our care. You know?
Unfortunately, obviously, all of the growth that we
experience is due to other downstream challenges in
our health care system and and patients not
being able to access the right care in
the right place at the right time.
And so, you know, for us, it's
it's less about how do we get more
patients in the door. But, you know, given
that there are more patients coming in the
door, how do we grow our functional capacity
to care for them?
Because, again, without without being able to usually
grow our physical spaces,
it's it's about how can you see more
people with the same resources. And so a
lot of times that is,
you know, just traditional
operational efficiency. You know, how do you triage
more efficiently? How do you, move patients through
the the standard phases of care, get their
labs quicker, their imaging quicker, their consultations quicker
so that they can get dispositioned and you
can make more space for the next patient.
Sometimes it is, you know, utilizing technology
to develop,
you know, novel treatment pathways. At Stanford,
we have a virtual visit track. So patients
who show up to our ED,
if they meet criteria,
can get, funneled over to a,
a telemedicine
track where they sit in front of a
computer, and they're seen virtually by a remote
emergency physician who can still give them all
the care that they need, and and those
patients get through a lot more quickly and
get home.
And then it's also, you know, how can
we think about
it's because because the walls of our ED
aren't gonna change. How do we expand the
care we provide beyond the walls of the
ED? How do we,
you know, intervene when a patient is considering
emergency care
and, you know, either either make sure that
they come in to get it or make
sure that if if they don't need to
come in, that they're still getting the care
that they need outside of that. So, for
example, you know, again, at Stanford, we have
set up a program where we've got a
telemedicine card at a local skilled nursing facility.
And, you know, when they're contemplating bringing appreciation
into the ED, they instead put them in
front of the cart. And one of our
EM docs is able to to very often
care for them there on the spot preventing
an ED arrival. And so those are kind
of some of the ways that we're thinking
about how do we,
given that our volume are is expanding, how
do we expand our ability to provide care
for this larger patient population with the same
resources?
Do you think the virtual visit track has
already made a big difference in terms of
efficiency?
Oh, yeah. I mean, so,
and you kinda had to think of efficiency
a little bit differently, actually, when you're talking
about things like the virtual visit track. So,
you know, is is that doc churning through
as many patients per hour as they are
in some of our other zones? Frankly, no,
if you look at the statistics.
However,
you know, when you got somebody who is
seeing sometimes
22, 23, 24
patients a day, and they're doing it just
with a cart. No ED room necessary.
That's huge. I mean, that is 10%,
of our daily arrivals,
and we don't even need a bed.
And so it's,
definitely resource efficient when you're talking to the
when the resource is the geography. It's tremendously
efficient on that front. And then it's also
very efficient when the when the resource you're
talking about is that patient's time. They get
through much faster,
and they they don't crowd up our our
ED waiting room quite so much. And then,
you know, actually, it's turned out that,
it's very popular from a patient perspective as
well. It's
surprising to us, but it continues to be
our most popular zone in the ED right
now. And so,
you know, it's it's when it's safe care,
the patients like it, and it's very efficient.
I mean, it's it's turned out to really
hit on all fronts.
Sounds like it's popular for good reason there.
Let me ask you, what is one risk
or investment do you think is worth making
this year?
Yeah. I mean so I I think there's
there's
probably a few
a few things to think through here, but
I I would say
this year going into '26,
I think
it's a very important time for EDs to
start integrating things like predictive analytics into their
workflows.
This is a kind of thing that I
think three, four years from now even will
be
absolutely standard, and emergency departments that have a
bit of a jump start on how to
utilize them are going to be,
you know, ready for the continued increase in
in patients coming through our doors.
So, you know, we're we're
planning to implement in the coming year, for
example, predictive analytics at the point of triage
to help us
determine whether a patient is appropriate for things
like our virtual visit track or our vertical
work streams, or can they just be discharged
from the waiting room, or do they we
need to send them to one of our
high acuity areas so that we can make
sure we're utilizing,
you know, our care spaces most appropriately. We're
looking at utilizing it, upstream at the hospital
capacity level so we can better predict ED
inflows, surgical inflows, transfer center inflows.
And, therefore,
you know, kind of pre pull levers some
of our interventions when we anticipate we are
going to have heavy capacity days rather than
being quite so reactive. And I think by
doing that, we'll harvest a lot of efficiency.
And then, you know, there's a lot of
other opportunities here. I think from, like, a
a needy
operations and management standpoint
using,
AI for charting, I think, for us, we
we've been doing this already, has produced more
thorough charting that is more amenable to being
coded appropriately so you can get paid appropriately
for the work that you do. And then,
you know, I I think once you've got
AI that's got access to some of the,
you know, ED notes and also the structured
data in the chart, there's a lot of
additional opportunities,
I think, as well.
A lot of additional opportunities as well,
for us to start predicting things like, you
know, which patients might benefit from early palliative
care intervention, which patients are likely to need
ICU care, and therefore we can, you know,
move them up there more quickly and also,
you know, convey that information to the, you
know, the hospital
capacity leads.
Or, you know, even which patients are likely
to have a bad experience where while they're
there. So we can utilize kind of our
our,
our resources well to, you know, help smooth
some of that over and, you know, make
sure that all of our patients are getting
the care that they need with, you know,
in in the manner that that meets their
needs. So I think there's a a lot
a lot of opportunities
that,
it's worth dipping our toes into,
if not jumping in with both feet in
'26.
Because I think these trends of increasing volumes,
increasing acuity are not really going to stop.
And so these are the types of tools
we gotta get facility with quickly so that
we can not be overwhelmed in '27 or
'28.
And the last question I have for you,
doctor Rivera, where do you see the best
opportunities
for growth in the future?
So
I think I think we've talked about one,
which is
predictive analytics,
AI enabled,
care and operations within the walls of the
ED.
You know, I I do think another area
again, growth is interesting concept in the emergency
department. So another interesting
another way that we can think about how
to extend our capabilities
is through this idea of expanding emergency medicine
beyond the walls of the ED. And we
talked about a a few of those ways
that that can be done, I think, through
telemedicine,
you know, telesniff programs, tele EMS programs, which
are very analogous.
On the other end of the spectrum,
hospital at home programs, and that's something also
that we're looking at at Stanford is, you
know, discharging people from the hospital a little
bit earlier than we otherwise would.
But we do that because we have a
remote provider who can check-in on them and
get them the last, you know, vestiges of
what they would have gotten inpatient. And we're
looking at doing that from the ED as
well so that we can take patients we
might have admitted to a physical, you know,
clinical decision unit or an ops unit and
instead do ops at home.
I think those those are some big opportunities,
that and we have the technology to do
now. It's just about the workflows. And then
on the other end, you know, the spectrum,
I think
there's in addition to things like telesniff and,
tele EMS control,
there are, I think, a lot more opportunities
through digital health and telemedicine to provide patients
with tools and education in real time as
they're contemplating ED care,
that can,
you know, prevent visits,
that are unnecessary
and get patients a little bit better targeted.
So I I think, there
I know at Stanford,
a lot of our outpatient
clinics have now converted to telemedicine, and many
of those in conjunction with, like, remote patient
monitoring tools,
are able to identify patients who,
are,
you know, having chronic issues with their chronic
diseases
escalating or, you know, other concerns that might
eventually lead to an emergency presentation, and they're
able to intervene remotely,
before that happens. And so I think those
are
again, it's not about expanding
space. Of course, if your an ED has
the opportunity to expand your your care spaces,
you should probably take it. You're probably gonna
need it. But most of us don't have
that, and so it is,
extending our ability to care for patients into
the pre and post ED visit space,
to make sure that they're getting the right
care in the right place at the right
time and making sure that the precious ED
space that we have is utilized for those
who need it most.
Doctor Roberta, thanks so much for joining us
on the podcast. It was a great conversation.
I look forward to working with you again
soon. Yeah. Thanks so much for having me.