Let Physicians Impact Change – Dr. Bradley Younggren, Chief Medical Officer, 98point6

SHIV GAGLANI: Hi. I'm Shiv Gaglani. Today, on Raise the Line. I'm really happy to be joined by an old friend of mine, Dr. Bradley Younggren, Chief Medical Officer of 98point6, an AI-powered, text-based mobile platform where U.S. board-certified physicians can provide primary care. Dr. Younggren brings nearly 20 years of experience working as a physician and still practices as an emergency medicine doc at EvergreenHealth, where he also serves as the medical director of emergency preparedness trauma and urgent care. 

He has also earned both a Bronze Star and the Combat Medic Badge for service in Iraq as a U.S. Army physician. I met Brad back in 2013 at a TEDMED event where we both were participating in something called the “Smartphone Physical” back when he was working at Mobisante, which is a smartphone-based ultrasound device. Brad, good to see you again. Thanks so much for being with us today.

DR. BRADLEY YOUNGGREN: Appreciate you having me. It's nice to catch up.

SHIV GAGLANI: For our audience, one of the first things we’d like to begin with is how did you get involved in healthcare? What made you decide to become an emergency doc and also to enlist in the army? 

DR. BRADLEY YOUNGGREN: I went to the military medical school, and I was very interested in disaster and humanitarian medicine. That was the primary reason I had gone into emergency medicine and did spend a fair amount of time in my military years supporting that work, but what happened, obviously, post 9/11, was we found a lot of us were downrange supporting soldier care in the Iraq and Afghanistan conflicts. I got involved in procuring technology on the battlefield and really saw, early on, how that scaled to save lives. It sort of ended up being a really pinnacle change for my career. 

I really started to focus on medical devices and digital healthcare technologies and how those can save lives on a larger scale. That led me to my first chief medical officer job at Mobisante back in 2013, when we met, and then I spent some time with a global health company before moving to QU Health, which is doing at-home lab testing and diagnostics, and then came to 98point6 at the end of 2016.

SHIV GAGLANI: Now we'll definitely get into 98point6 and all the amazing kind of drastic changes that have happened over just the past few months, let alone a few years, but before we go into that, I'd love to hear more about your experience in Iraq. I think you're the first physician who's served we've had on the Raise the Line podcast. I'm sure it prepared you to do a lot around digital health. Can you talk a bit more about what types of things you remember from that experience and how it's contributed to your work today?

DR. BRADLEY YOUNGGREN: It's the best clinical experience of my career and the hardest work and emotionally challenging to take care of people that you know. It's very different from being a physician, and clinical practice where you don't really know your patients to the same degree, especially in emergency medicine, my field, as opposed to taking care of 250, 500 soldiers who you know them, their families and are deeply intimate with their lives. That's a very different experience and then quite an honor. It’s the best job in my career, I'd say.

From the technology side, it was an interesting time because portable ultrasound technologies had just been deployed. It came up to the market, so we were figuring out how to move those across the battlefield to make decisions around triaging and medevacing patients. We had a lot of mass casualty events with penetrating trauma from IEDs so these kinds of technologies were really useful, and they were really brand new. The portable machine had literally just come out, so we were exploring how we'd move those around to save lives, push them forward in the battlefield, and how that impacts medivac and patient evacuation, and then we started actually looking at VOIP (Voice Over Internet Protocol) technology, how we could really do virtual telemedicine from the battlefield to get guidance or assistance around imaging so they were really the roots of telemedicine for the army back then during the early parts of the war.

SHIV GAGLANI: That's pretty incredible. Some of the stuff that you saw in Iraq, both with regards to telemedicine and disaster preparedness, have probably come full circle in the past, just a few months here. I'd love to hear more about what you've seen at EvergreenHealth before we go into 98point6. You're in Washington, which was really the first state to get hit very hard and has done a pretty good job, it seems, of managing the pandemic. Can you talk a bit about what you've seen over the past few months and how your practices have been affected?

DR. BRADLEY YOUNGGREN: I think that I've been at EvergreenHealth since I got out of the army, and just because of my previous work took over as preparedness director from the moment I got there. Additionally, I sit on the County Disaster Medical Advisory Committee, and then there's a state committee called the DMAC that supports the Department of Health of the State of Washington, about 20 physicians, and I sit on that advisory council that advises the EUA. Fortunately, the hospital was invested in a preparedness program, allowing us to preposition PP and so forth. Certainly, we couldn't have anticipated that the first real cases would have come into every hospital. 

Literally, all of a sudden, we were putting in 20 hours a day, trying to contact trace the original cases from Life C are. All of a sudden, overnight we had a number of positive cases as you know, and really, let's say late February, March, and April, it was just kind of a blur of just both on the local level, as far as working at Evergreen in trying to get that system under control. The hospital did a phenomenal job. They were working with the state to develop a disaster response plan and pandemic response plan to deal with all the cases we had in the State of Washington at the time. Also, at the same time, there was quite a bit of work going on at 98point6, and we saw a massive surge in volume. It’s been well documented. Virtual care took center stage in many forms, and 98point6 was no different, so I was really kind of on all fronts. The pandemic response was quite impactful.

SHIV GAGLANI: Around the time I emailed you about first appearing on this podcast, you said, “I'd love to, but I'm a little busy right now,” so I fully understand what you were going through with that and I appreciate all the work that you've done. Now turning to 98point6, it's been a whirlwind few months, and one of our recent guests on the podcast is Joe Kvedar, who runs the American Telemedicine Association. Can you tell us a bit more about both the fundraising 98point6 did recently, as well as any statistics you can provide us in terms of the surge in demand that you were just talking about?

DR. BRADLEY YOUNGGREN: Yes. We finished a Series D round back in March of 2020. That's been great. There's certainly a lot of interest in the space, and from the perspective of the surge, we started building a surge capacity planning program back in December of 2019 because I was looking at what's going on in China and trying to understand how that could potentially impact the work we're doing. One of the things that's unique to 98point6 is we employ our physicians. They’re full-time employees. That's been our approach since the beginning. It's a very physician-focused medical group practice. The benefit of that is we knew exactly what our surge capacity was if we were all hands on deck, we took away administrative time and everyone leaned into patient care, what kind of productivity and support could we get from the practice as opposed to when I was sitting in meetings with the federal government and other telemedicine companies, and they were saying, “Well, I have to 2,000 people.”

I knew that those people were being crossed-counted through all those organizations because they’re locum tenens physicians working for 5 to 10 telemedicine companies at the same time, so it was just a fundamentally different, unique approach. We had a certain capacity plan built in, and then when the CDC came out with guidance in January around travel guidance, we actually imported that into our AI algorithm and had picked up a few cases in January that were reported to CDC. That was really interesting for us to start to take outside input from organizations like the CDC and build it into our neural network. Obviously, after things hit at the end of February, we had massive surges in the clinic, 300% or 400% volume surges, and 40% to 50% of cases on an average day were COVID, or COVID-related.  

We found ourselves doing a lot of work that, really, I don't think anyone had solved before. We work with quite a bit of labs, and we've been doing that since 2017. We're one of the largest lab ordering virtual care companies in the country now, primarily because we believe that's a component of virtualizing primary care. It has to include lab ordering for standard labs, but we had to really apply that knowledge to the COVID-19 pandemic crisis, which is how we get people PCR testing at the time, and as you know, from those early days, it was very fragmented. There was not a nationalized system to plug into, so for a company that's operating at a national scale, 24/7, 365 in 51 jurisdictions, we really had to get down into the weeds to understand what were the opportunities for PCR testing and referrals in those different markets.  So we spent a lot of time on that care coordination of the lab piece to get people what they needed from that perspective, and then provide them with appropriate follow-up and guidance. 

SHIV GAGLANI: Actually, another one of our guests was Julia Cheek from Everlywell. She talked about some of the same issues. What type of infrastructures did you have to build to solve that issue of mass testing basically?

DR. BRADLEY YOUNGGREN: We actually ended up helping facilitate some of the work that happened in the State of Washington around the lab hub testing with Quest for the self-swabbing. They came out, and they gave us a kind of a mission to facilitate some of that work. It was a bunch of Seattle companies working on that back in March to try and get that work done. Lab testing is interesting. It's not always just about getting a test. It's about getting good, high-quality tests, so we spent a lot of time deciding who we thought were the appropriate partners, what kind of testing we thought was validated in the market. As you know, when the Emergency Use Authorizations from the FDA started rolling in around lab testing, the question was digging into the data to understand, “If we're going to recommend a test to our patients, we want to have confidence on the sensitivity, specificity, negative predictive value of that testing,” so, early on, we really focused on working with partners like University of Washington’s Fred Hutchinson Virology Lab. 

We've been a great partner with Quest for some time, worked with LabCorp as well to create opportunities for lab testing when we could, and then, as other partners came in the regional markets, we would sort of add them to our technical platform. The good thing about having essentially an AI-based technical platform that's homegrown and built by yourself is you really understand the engineering behind it, and so you can add in features around this lab testing, not only from the patient's side but the physician facing side.  Remember that our doctors are taking care of patients in 51 states and patients that are raising their hand saying, "I need a lab test." It's very different to do it in your local market, as opposed to some other state where you actually don't even understand the regional variability that exists in testing opportunities, so we had to build that into the product to facilitate those kinds of testing parameters for the doctors.

SHIV GAGLANI: That's really interesting. Again, I've heard two pretty unique things about the 98point6 model. One is you employ your physicians. The second is that you have this AI-powered triage system. Can you talk a bit more about those two and then any other kind of differentiators, because this is obviously a time that many people are focused on telemedicine, Livongo, and Teladoc merging, and Amwell going public, and MDLive has just raised money. We'd love to hear more about what makes 98point6 different.

DR. BRADLEY YOUNGGREN: Thanks. I appreciate the question. I'll start with the medical group, which is one of the verticals that falls under me. I came to 98point6 towards the end of 2016, and we were going to start seeing patients in February of 2017 in the State of Washington, Robbie Cape, the CEO, said, “Just spend three months building the clinic of your dreams. Go spend some time on this,” and the expectation was that it would fulfill all the shortcomings of current brick and mortar practice.  So being a physician, I was really sensitive to the notion of “what do we need to do to be different? “

From my perspective, the largest thing I saw in the market was how do you understand what quality of care is being delivered when you have a large number of locum tenens physicians operating on your platform? By the way, the platform isn't recording anything, so you have no data. Then I knew that we were going to have the data, and I thought that was really going to be unique, that we could pull data out of the system to understand how the quality of care is being impacted through virtual visits, but I thought the starting foundation point was to employ physicians.

Our original core physicians operated on what we called at the time, in the 80-20 rule so they all have time to attend meetings and they all had non-clinical time to work on product development, and they all have done clinical time to do peer to peer chart review because we knew that was going to be critical. We wanted to make sure we carved out that time for them and protected it. All physicians have equity in the company. They're not only in the boat, they are rowing the boat. That's the thing that makes us unique in the market. I think physicians love coming to work for us because we all know, as physicians, what the problems are in healthcare. We've seen it. We live it. We feel it every day, whether it's problems in the system, whether it's problems in the technology we're forced to use, which has a negative impact on burnout. You can name it. 

The key feature is creating a physician workforce that's allowed to impact change so our physicians are providing daily feedback to the product development teams about features that they would like to see or that aren't working correctly. They get feedback on the same day from those product managers. That's not what happens in hospitals. It's a fundamentally different approach that we have in terms of how we approach hiring doctors to the point where, when we look at net promoter score, which obviously many companies use to look at how patients, in our case, are viewing their experience, we weigh the physician experience. We have a metric for that. 

We check it just as vigorously as we do on the patient side because we know that's where the magic happens --  it's when the physicians are happy and excited because they went into medicine for a reason. They want to help people. They want to help as many people as possible. We just need to give them the opportunity to do so. That's the fundamental approach of our medical group, which I think is unique and exciting and gets people really motivated to come on board full time with us.  And then as far as the AI neural network, I think the thing that drew me to the company, what I realized, is we were going to make the investment in building a platform that leverages the AI in the delivery of care, and that's fundamentally unique in the market. 

We're not an AI symptom checker that spits out a list of 10 possible diagnoses, and the doctors have to go back and start from the beginning. It's investing in technology that allows the doctors to operate at the top of their license. The doctors see 100% of our cases, and the AI that people see on the website is the chatbot that helps gather findings from patients, but there's a bunch of other technology in the back that's actually assisting the physicians to provide not only efficient, but high-quality care, the highest of quality care, and the physicians get to operate within that AI-based system, which is very exciting for them.

SHIV GAGLANI: That's pretty remarkable, hearing it in your voice right there, the enthusiasm you have for the model that you've built. How many physicians do you employ, and given that our audience is composed of millions of current or future clinicians, what would be your pitch to them to come work at 98point6?

DR. BRADLEY YOUNGGREN: We have about 55 full-time doctors right now. We're continuing to hire in the pipeline. I think I probably already said it, but I think that the notion is for the better or worse,  we treat our physicians no different than we would our software engineers. I tell that to the doctors upfront. For me, as a CMO, I love that. Sometimes doctors are kind of used to being treated a bit differently. Our hiring process is the same. If you want to get hired at 98point6, it's no different if you're a physician or you're a software engineer or a data scientist or marketing manager, and I love that. That's something we borrowed from the technology space because in a lot of ways, we're a technology company at our core. 

The fact that all the physicians have an opportunity to be part of something and actually help to build it, and that we are dedicated to giving them time to not only provide high-quality patient care but to impact a variety of domains, allows us to kind of put people in their sweet spot. We have one physician who works on a Facebook group for mothers, and we just let her go. We gave her some training around interview techniques. She just loves the company, and she's brought in probably 15 to 20 doctors because she's out there talking about what her life is like as a 98point6 physician, so we are finding the sweet spots and getting people motivated. Some people want to work on quality. Some people want to work on product development, and we just try and drop people into the area of work that motivates them, again, because they're employees of the company and they have equity.

As I tell our doctors, "This will be your last job. If you do this right, this will all be your last job," not in the short-term, but in the long-term. Our North Star in the company is that we believe that everyone in the world should have access to primary care, and no one should have to make a financial trade-off to get that primary care. That's a longhaul mission, of course, on a global scale, and we think that we are heading in the right direction, which is we can do that and provide that kind of care across the country and across the world.

SHIV GAGLANI: That's pretty remarkable. We just had Cyril Philip on the podcast, who's at Providence Ventures up in your neck of the woods in Washington. Providence obviously is a huge health system. One of the points he made is that as Twitter and Facebook and all these other companies are going to full “work from home”, and as more physicians and other care staff are doing virtual care, as you are familiar with, and they're working from home, the scope of practice is really interesting. 

We've obviously seen a lot of regional consolidation of health systems and hospitals buying up practices, but with companies like 98point6, which --  you are headquartered, I believe, in Washington, but you're already in 51 states -- what are some of the mind shift changes you have to do to get those physicians? Is it just physicians, or do you also have nurses and other types of health professionals on staff? How do you train them to get used to this virtual care telemedicine type model? Do you just find people who inherently do it because that's obviously what they want to do? 

DR. BRADLEY YOUNGGREN: One of the verticals that sit under me is the training team, which is interesting, and it's grown. They create the training modules for the new oncoming physicians. What's interesting is as we grow, the iterations on the product go faster and faster, so every week there's new product training for all the doctors because that's how fast things move. There are issues around quality, so we have to have a really robust training program. We do have a bunch of work on the front-end to make sure we find the right fit for physicians who want to come work for us, but that is quite varied. There is a lot about core values. 

Do your core values match up with our 20 core values? Do you believe in critical, informed thinking? Do you believe in innovation? Do you believe that every human on this earth should have access to primary care medicine? Are you willing to put in the time to make that happen? We've used that approach, and it's been really great so far. We've had no shortage of physicians. The virtual thing has been great. That's how we've always been. I think a lot of physicians have opened their eyes to some of the virtual work they've done with their health systems and realized it's kind of nice to have some flexibility. Our doctors live and work in all 51 States -- I mean, we don't have doctors in all 51 States, but we have them in all the time zones, and we have a big cadre in Hawaii as an example.

What we've been able to do is create a 24/7 schedule in which our physicians don't work nights because we can have a clock that follows from West back to East, and allow a system where from a physician wellness perspective -- as an ER doc, I know what the impact of long-term night shift work is for physicians -- we actually couldn't find a way not to do that, so we've created a system that allows all physicians to live a relatively normal life and create flexibility in their work schedule.

SHIV GAGLANI: That's incredible. Obviously before COVID,  burnout was a huge issue, especially in emergency medicine, which you're familiar with.  Are there statistics showing that people who provide virtual care or going to telemedicine are less likely to burn out, or they have longer kinds of practice durations?

DR. BRADLEY YOUNGGREN: I don't think they've seen any studies on that yet. We're targeting things we do know which is that night shifts are bad. Physicians being on the outside looking in has been bad. This notion around physicians wellness is something that we take seriously. We learn a lot from those surveys and those metrics that we cover, getting into the level of understanding the biometrics of physicians that work for us, if our physicians are proposing additional work in that kind of space, it will help us inform how to create a high-quality environment for them to work in. 

SHIV GAGLANI: That's awesome. Switching gears real quick to go from the provider side to the patient side, if I'm a patient of 98point6, how do you view both education as well as getting the patients themselves technology, whether it's watches or ultrasound, even like the Smartphone Physical stuff that brought us together in the first place.  How do you view education as well as devices to collect more accurate patient-generated health data at 98point6 now, and where do you see it in a couple of years?

DR. BRADLEY YOUNGGREN: We refer to the care plan as the patient education at 98point6. The first thing we did many years ago is doing an open note policy, which isn't that unique or interesting. Most hospitals have done that. I asked the doctors to consider an open transcript policy. That would take a number of months to accomplish, and the doctors did it in 48 hours, and the response was, "That's why we're here, to be innovative and different." We all thought that providing the chat transcript between a doctor and a patient in the app that you can go back to as the patient would be one of the most valuable things you could do for someone. No one had done that. We've been doing that for a while now. 

For every visit, you can go in, look and review your chat transcript at the very least. We have a care team, product engineering team with the physicians that work with us, gathering data around this. I think this is an opportunity for massive amounts of growth. I always say the starting point was that, in the ER, we hand out 10 to 20 pages of printed work that all the studies have shown patients never read. That's the engagement we're starting from, and we want to move to a place where the patients are engaging in the app, that they find it educational and valuable, that the follow-up plans are an engaging way that they can get to. They're actually coming back on the app, not just to engage in patient care or to talk to a physician, but to go back and look through those care plans. 

That's a great area of opportunity for us. One of the benefits of working with Rob Schwietzer, our chief product officer is he ran Amazon Prime for many years. One of the things you get from having a chief product officer like that is understanding consumers deeply, in this case, patient behavior and being able to iterate to provide a high-quality, in-app mobile experience that really helps patients be engaged and move them from sickness care to wellness care, ultimately, which is our goal.

SHIV GAGLANI: That's incredible. I know we're running up on time. I have two last questions if you don't mind. The first is, what do you think some of the lasting changes coming out of COVID-19 will be for the healthcare system?

DR. BRADLEY YOUNGGREN: I think that the health systems have definitely had to stand up virtual care overnight, within weeks moving their whole book of business onto virtualized care. We've seen some move back across that, probably driven by the fee for service business model. So some patients are being driven away from virtual care. But I think everyone could comfortably sit with a statement that virtual care is here to stay. 

We're doing something different. When you can layer a bunch of connected data, that impacts the physician and patient experience.  One of the things I hear from my cardiology friends around some of the EKG stuff on the market is it's very challenging for them because they get sent all this data from their patients. One, they don't get reimbursed for it. Two, it's hard to sift through it. It's not curated in a way that physicians can consume the data fast, provide actionable data, and it impacts patient care, which is what we want to do as physicians. I think the ultimate magic around there is if you consume all those connected data, and then put it in a way that could create actionable information for the physician. That's where the magic will happen, and that's where we're headed. 

I don't know if it's going to happen on the health system side. My hunch is it'll happen more on the direct consumer side, out of system side, non-traditional setting sides where you'll see more innovation from tech-oriented companies that are coming in and trying to solve problems that have existed in the traditional healthcare system for quite some time.

SHIV GAGLANI: As you were just saying, having a chief product officer who came from one of the most successful tech companies in terms of putting customers first is very interesting and could be compelling and hopefully mark a shift. The last question is, you've done a lot of innovative things and maintain your practice as a physician. What advice do you have for current students who are considering careers or already on their journeys to careers in healthcare? 

DR. BRADLEY YOUNGGREN:  It’s so easy now to look back. I graduated med school in 1999, but I struggled to figure out what residency to do, and I think that in the end, I made a decision which was right for me at the time, which wasn't about tech, but it was about this motivation around disaster and humanitarian medicine because those were in my heart. I think that finding what's in your heart and going after that, you'll be a better doctor for it. Finding mentors in that space that can guide you, that you look ahead 20 years and you find those people, whether it's technology and healthcare, whether it's traditional healthcare modalities, it doesn't matter. Finding role models and mentors is critical. 

I find them now. When I got into digital care, I found people.  I started meeting Bill Crounse, who was the CMO of Microsoft at the time because I just wanted to talk to people who have been in positions in technology and those kinds of relationships are incredibly valuable to me even today. From the medical student perspective, that's critical. You never know which ways the financial world will turn, so don't select bodies of work based on financial remuneration. Find out based on motivation and things that you want to get up every morning and be excited about. That's how medicine is a long-lasting career.

SHIV GAGLANI: Totally. Again, you've been sort of a role model and inspiration to me, as well, ever since I met you at TEDMED and in general. I really appreciate you taking the time to be with us today, given how much you're doing both at 98point6 and EvergreenHealth. I invite all of our learners to check out the work that you're doing. With that, I'd like to thank you again for your time. I'm Shiv Gaglani, and thanks to the audience for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together.