Podcast with Nader Mherabi, Chief Information Officer, NYU Langone Health

Welcome to the big unlock podcast where we discuss digital transformation and emerging technologies in healthcare. Here are some of the most innovative thinkers and leaders in health care and technology talk about how they are driving change in their organizations.

Paddy: Hello again everyone and welcome back to my podcast. This is Paddy. It’s a very special occasion for us today. It’s our 25th episode and it’s my great privilege and honor to introduce my guest for today Ed Marx, CIO of Cleveland Clinic. Ed, I want to start by mentioning you were our very first guest on this podcast. I greatly appreciate your support. Welcome back.

Ed Marx: Thank you and I’m honored to be back and to have been your first. I’ve enjoyed, I think I’ve listened to most of those twenty-five and I think it’s an excellent resource for other leaders.

Paddy: Thank you very much. Very kind of you. Ed, I wanted to start with this. You’ve had two major health events in the past twelve months or so. You’ve blogged about both events in an extraordinarily candid way. Would you care to tell our listeners a little bit about what you went through?

Ed Marx: Yeah. It was very strange. Both were surprises. If people know much about me, I’m a pretty healthy individual and undergo a lot of routine testing just because I want to stay at the top of my game. My coaches make me do so and my wife certainly makes me do so. And in May, let’s say March of 2018, I underwent an executive physical and for those who’ve ever had one, it’s pretty much an all-day affair where it’s very intensive physical as opposed to a 30-minute physical you might have with a provider. Typically, this is all day long with multiple providers doing multiple tests. And out of that they said, Ed, you’re in the top 1 percent in your age group in terms of health. And it’s surprising that, next month I’m in a race. I race for a pretty distinguished team and I was in the national championships and I had this pressure on my chest, just as I’d always read about or heard about signifying a heart attack. And I was like, there’s no way I could have a heart attack. I’m too healthy and I was able to keep running and just for the sake of time I won’t go into all the details. I kept running and which was somewhat foolish but somewhat saved my life and I reached the finish line, made the team and checked myself into the medical ten. Where using technology, they figured out pretty quickly I was having a LAD or what’s called the widow-maker heart attack, pretty much instant death. And thankfully I was still able to breathe, and my heart was still partially functioning. So, I got taken to a hospital where they put in a stent, cleared the blockage from my heart and immediately felt better. And through digital means, which I will talk about it in a minute, I was back 90 days later, racing in the world championships. So, it was really weird though, because there were no lifestyle reasons for it. It’s completely unexplainable. And so, you never know in life things can happen. So, you always have to be prepared both personally and professionally and so forth. And then, after a year I had my year checkup of April 2019. The physician took me off my drugs. I was completely changed my diagnosis from the heart attack because they said this was just a once in a billion event, there’s no heart disease or nothing. And I was pretty happy and he says but I’m really concerned about your PSA score and I said I’m not concerned about it because I’ve watched it over the years, my physicians have watched it and said there’s nothing to be concerned with, just to keep watching it. He says, now I would go see someone. So thankfully you know working in a health system, I have easy access and talked to the Chair of our Urology Institute and he invented this new test a year ago, which is much better than a typical PSA test, has predictive analytic capabilities. And I took it and the next morning he was sitting in my office at 6:30. I thought that’s not a good sign. And he said, Ed, you know based on this test you have 85 percent chance of prostate cancer. I was like what. And so, he said what do you do now. Basically, and I said whatever you want me to do and I had a biopsy done and got the results back quickly and sure enough, I had level seven prostate cancer. They don’t do stages like a typical cancer but it’s a level between zero and 10, seven is not good. If you have below seven, you know you can do other treatments but seven, if you want to be sure and get rid of the cancer, you have a prostatectomy, and that’s what I ended up doing. And thankfully a couple of days later, we were notified I was completely cancer-free. Often times you still have to go undergo radiation chemo but because of the radical prostatectomy and the lab work around that, I was completely healed. So, it took a little while, few weeks to get back into the normal swing of things but I’m back running and racing, have had three races this month already and I’m ready to compete. So, it’s been weird. But I learned a lot through this.

Paddy: Wow that is some story. And firstly, I want to thank you for sharing that, with that, it’s so personal. And for our listeners, I also want to mention that you’ve blogged about this extensively in a series that you titled ‘You have cancer.’ And you went into a lot of things, it’s not just about yourself but you talked about the whole system and how it works. You expressed a lot of gratitude for the caregivers. I was astounded at how you managed to track every single individual who was involved in your care. And you mentioned them all by name. So, kudos to you Ed. And again, extraordinary story. Firstly, I’m glad that you’re fine and glad that you’re back on our podcast.

Ed Marx: Yes, it definitely beats the alternative. I appreciate the fact that Paddy you were one of very few friends who came to visit me just to say hello and show your support. And you traveled a great distance to do that and I appreciate it.

Paddy: Thank you. Thank you. OK. So, you now have a unique perspective of the health care experience by which you’ve been a patient in one of the leading health systems in the country, where you are also the CIO. So, tell us about how you saw the two worlds converging. The world of the CIO and the world of the patient. How did you see that converging during your recent experience?

Ed Marx: Well, it was pretty amazing and I’m so thankful to be part of the Cleveland Clinic. I know there are amazing health care organizations around the world. I’m glad that in the two areas where I had an issue. We are number one in the world, in cardiovascular, neurology, and kidney. So, I was very fortunate in that regard. So, in the first one, it really doubled down on my passion for digital technologies and how we can impact people’s lives in a positive way. The quality of life as well as saving people’s lives through digital. And so, I became, the things that I was an evangelist of, I became a patient of and that’s digital. So, in the heart attack example, we had a little cardiac device attached to the iPhone, and immediately had an EKG reading. That EKG reading was sent to the hospital_____[unclear] and they knew immediately what to do, what we needed to do. They then took that image just as in South Carolina they knew as part of a Cleveland clinic they sent that image to the Cleveland Clinic. By the time, by 5:10 am the ambulance ride was finished, and I was about to enter the cardiovascular, the Cath lab, the images had been read by Cleveland Clinic, head of cardiology and as well as the local very fine interventionists. And then afterward, through Bluetooth technologies for anything from pulse, through heart rate, to blood pressure, to weight, everything was transferred electronically or digitally directly into my record. And as a result, my clinicians were adjusting meds in real-time. Normally you might have a four week or eight weeks follow up appointment, they take one blood pressure and then say, maybe, we should adjust your drugs. But because this is all real-time, they would get alerts all the time and then they would make adjustments accordingly. And that’s what enabled me to get back on my feet so quickly and like I said, 90 days later, I was competing in the world championships. So, it really makes a difference. And it’s the same learning, how innovative we are as a culture. This physician, the Chair of what we call GUKI, Glickman Urology and Kidney Institute. He invented this new blood test to give predictive capability as to the presence of cancer. And so, I was just thankful that I had access to that, and I saw it at work. And then going through the whole OR experience and watching all the safety, all the huddles. I paid a lot of keen attention because I’m exposed to this every day. I participated in huddles every day. And I was very keen and listening in and observing just how we practice, what we preach. And then it just doubled down again on my commitment to evangelism of digital because it saves people’s lives, including my own.

Paddy: You mentioned all the ingredients of the ideal experience where data flows freely from one part of the country to another. Or I should say one provider in one part of the country to another provider. It flows seamlessly and they’re able to pull it up and make real-time decisions or interventions at the point of care, uses an ideal experience. Of course, the healthcare as an industry is still maturing to reach that same level of consistent experience across the entire healthcare ecosystem. And we’ll talk about that in a minute. But you know Cleveland Clinic has embarked on an ambitious digital transformation program which started last year, and I was fortunate enough to be a part of that when I worked with you. Can you tell us how you are defining digital today and where you are in the journey?

Ed Marx: Yeah. So, I can’t say that we have an official definition. But the one that I’m putting out there right now and testing the waters with is, ‘leveraging technology to produce seamless experiences.’ So, we like to be very short and succinct with what we do. That’s six words to me, that pretty much explains digital and it is a major emphasis. I believe in our next board meeting our emphasis will be sort of on our digital transformation, where we are, where we’re headed and having some sort of definition that is very helpful. And then we give some additional definition around that, but that’s sort of the high-level definition and then the rest of definition. There’s sort of four main adjectives if you will and these are all surrounded by or supported by or let me say this way, the adjectives support our four corners of who we are and that is about the caregiver, about the patient, about the community, and about the organization. So, it’s all strategically aligned with the organization strategy and digital transformation is key to making our organizational strategy a reality.

Paddy: My firm’s research seems to suggest that most healthcare enterprises are in early stages of digital transformation. In fact, most health systems are pursuing digital as maybe a set of standalone initiatives as part of either a digital innovation program or as a telehealth program. And in some cases, they simply default into whatever the electronic health record system provides as an out of the box functionality. Very few are taking an enterprise view of the digital strategy and roadmap as you are doing today at the Cleveland Clinic. So firstly, do you agree with the general assessment of the marketplace and how do you see that change in the next twelve months?

Ed Marx: Yeah, I think we’re early stages, healthcare typically behind other industries. So, what you’re seeing is pockets of brilliance as opposed to sort of an enterprise strategy. That’s just how things develop and innovate. You know you think of some new ideas or just sort of pop up. And then eventually, get to a level where you start wanting to tie those things together. And then you mature to a point that, rather than taking that approach and having these pop-ups that you try to act, all you do is adding complexity by doing that. Then you’re like, let’s take a step back. And I think that’s definitely where we are. So we have had pockets of brilliance for years doing some pretty nifty things, really important things and I’m glad we did them and now we’ve matured to the point of we’re taking sort of this enterprise approach to digital transformation making sure that it’s in complete alignment with our overall organization strategy. In fact, if you look at our organization strategy, it cannot happen without digital transformation. It’s one and the same. So that’s been our approach. But it’s a maturing process. I think it’s hard to get there right out of the box. It’s almost as if in order to push the culture a little bit, for most organizations, you’re going to have to have these pop-ups, these pockets of brilliance that sort of set the standard. And say, hey, look it’s OK, it’s safe, let’s go ahead and move this direction. So, I think it’s just part of an evolution, it’s definitely not a negative reflection on any particular organization.

Paddy: Right. And it’s just the current state as it is. You mentioned a little earlier that, your one-line simple definition of digital transformation is using technology for seamless experiences. As technology obviously has a very big role to play in digital transformation. However, there is no such thing as an enterprise digital platform which means that enterprises and digital leaders have to be thinking about building their own digital platforms. What would you advise digital leaders?

Ed Marx: Yeah, now we went through the same thing. It’s like OK we have these pockets of brilliance, but this new strategy of the organization, how do we support that. And I’m a very visual person, I think many people are. And so, it took us a few iterations, but actually, on one slide, we created our digital platform. So, we basically again took those things that are most near and dear to our organization right out of our strategy. And then we said what is the underlying technology that enables these things. And so, we identified those things and then we even added some of our, I call them vendor/partners, to them that are providing some of those support areas for us. And then we could say, look we actually have a platform and then people get more engaged because they can look at the platform and that makes it more real and then they can help make it better. We always talk about how we iterate on things and so we went through a process of iteration and making it better. And so, we have a pretty robust platform now. So, when someone asks what is your digital platform? I can actually show them a digital platform and it’s aligned with our organization. And it helps my peers, because oftentimes they’ll be tempted to go run off after a specific technology. I’m like, wait, let’s look at our digital platform and see how that fits in. How does that fit into virtual health? How does that experience an engagement? And, these are the different objectives for each of those and here are the primary vendor partners that we’re working with. And so, it’s a very helpful tool.

Paddy: So would you say you’re pretty much complete in the process or are you still putting some pieces in as part of their digital platform today?

Ed Marx: Yeah. You know one is too small a number for greatness, you can’t go on this alone. This is not a solo trip. I think in about half you could do things by yourself but not today. And it depends on your organization, we’re a global organization. So, we need a global partner to help us. And so, we’ve identified a small handful of potential global partners. And so, when you look at our digital platform, there’s probably, out of I want to say 30 sub-components of our digital platform, 20 of them will probably be filled by a single partner. And I think that’s important because everything’s so integrated and I don’t want to make things more complex they need to be. I believe in simplicity and not only does it increase overall value but drive down costs. And it’s easy to understand. So, it’s easy for other members of our organization to understand why we do the things that we do how they’re all interconnected. And then we can leverage because of the scale of these sort of relationships. You get a lot of benefits; you get a lot of backward investment into your organization. And your views align with the right partner, you can really do wondrous things for your community or as I mentioned for us, it’s more on a global scale, but you can do wonderful things. It’s almost an ethical imperative that if you have this great product or service and we believe we do and specifically in healthcare, then we want to share it with as many people that we can in easy to understand format and by having a partner sometimes you can do those things a lot quicker.

Paddy: And I think you provided a good thumb rule if you will. If you have about 30 components or so that need to go into what you would describe as a digital platform. Well, two-thirds of those components are going to come from a very small handful of strategic global partnerships and the rest, of course, you’re going to go for best in class technologies or very specific technologies as the case may be. That’s great thumb rule, at least, something that people can relate to. Switching topics here. Let’s talk about the organizational structure for digital transformation. You mentioned earlier on too, that it’s about collaboration, no one can do this alone. It requires teamwork, stakeholders within and outside the organization. Again, our research indicates that when it comes to the digital leadership role there’s quite a lot of variation within the industry. For the most part, digital leadership seems to fall on the CIO today. However, a number of leading systems have also appointed leaders who are dedicated to just that role and in some cases, they are even coming from outside the industry. So, can you comment on this trend? Can you comment on what the emerging trend as far as their org structure is concerned for a digital transformation to be successfully executed by health care enterprise?

Ed Marx: My perspective, for me, I’m less concerned about organizational structure as I am the person filling a particular role. I think if you have the right CIO, you don’t necessarily need to also have a CDO. Now it really depends on that person. I always say, disrupt or be disruptive. If you’re a CIO and you have a traditional mindset, traditional skills, you’re going to be disrupted. And your organization probably going to have a CDO or if not a CDO, other people sort of leading the digital transformation. But there’s no reason as a CIO that you can’t be both CIO and help lead digital transformation. Again, it’s a skill set, it’s a mindset and it’s really about collaborating with your peers. That’s why I don’t really care where it sits. It’s really about being a collaborative leader that you collaborate with nurses and physicians and other clinicians and strategy and business development and finance. You know the whole thing. The second thing I would say is I am very much supportive of individuals coming from outside of health care. I think one of the reasons our growth has been retarded is that we’ve become very insular over the years. And if you just look at some of the policies that you see, when it comes to hiring and it says must have 20 years healthcare experience. Why? If healthcare fine. Why do you want 20 years healthcare experience? I’d rather bring in people and have a healthy mix from outside and inside. Maybe get someone from manufacturing or someone from finance or entertainment, some more progressive field and then have them as part of your team. And that diversity makes for innovation which makes for digital transformation. I’m a big believer in pulling people from outside IT, not outside IT but outside healthcare. Again though, it’s not one or the other, you can be all those things, you can be that CIO that has a fresh mind, fresh skillset, collaborates. And at the same time brings in people from outside of health care into your organization to make it stronger. You can do all those things.

Paddy: Yeah that’s very well said. Coming to the question of the investments that are required. Obviously digital transformation is a multi-year effort. There are significant investments that enterprises have to make, and they are making across the board. A significant amount of IT budgets or technology budgets in healthcare are consumed in maintaining legacy environments. And you hear of some of these big numbers and somebody has to upgrade an EHR system for instance or somebody has to upgrade their infrastructure, for instance. A lot of that goes into just upgrading your existing environment and part of it is necessary because without the state-of-the-art environment, a lot of the digital functionalities can’t even be turned on, they just won’t work. How do you kind of trade-off between the need for your legacy environment to be refreshed versus the need to invest in futuristic technologies as well?

Ed Marx: Yeah, I think there’s two things. One is you definitely have to be bimodal. I’m sure all of us you know 90 percent of CEOs deal with this where you do have a lot of legacy things that you have to take care of and continue to pay attention to. It’s a common problem. But you can’t use that as an excuse. You also have to be looking forward, and I think about that from strategy and operations you know I need to make sure that I’ve got the right people making sure things operating well. And then looking towards the future and then trying to spread investments the best I can depending on my situation. You got to operate both. It’s not like one or the other. That’s definitely a key component. The other thing is to become more and more data driven. I believe in data over emotions. And if I can really quantify the need, if I can benchmark myself, if I can really quantify all that we do. So, another example, I mentioned a couple already just now. But another one would be, what time is spent, do you do time tracking and then do you look at the analytics behind that. What time is spent on legacy? What is spent on, we talk about run, growth, and sort of transform as our three buckets. And we have our OKR and objective key results on each year that attempts to move 5 percent of the run into both transform and grow. And we can show that. And then when we talk with finance or strategy or others about investment and improving IT, we use data now to show look in the last two years we’ve increased our spend into areas of transformation and growth. We’ve been good stewards. Give us more and we’ll continue to make that transformation. But if we didn’t have data and just did it based on philosophy or our ability to argument in the moment we’d be in big trouble. So, both being bi-modal and then being data-driven helps to overcome that.

Paddy: Right. Right. One question that has come up and I’m sure you’ve had this come up to you as well. Cleveland Clinic is a big organization, you have a lot of budgets you’re able to make a lot of investment. You have the luxury of taking a longer-term view. But if you’re the CIO or a leader of a regional, the smaller regional system or community hospitals somewhere, it’s a matter of survival on a day to day basis because of the nature of the marketplace today. What’s your advice for them? What would you say to them, if they say look, this would work for the Cleveland Clinic doesn’t necessarily have to work for us because we’re in a very different place?

Ed Marx: Well two things: One is I would challenge that assumption now. I have worked in community hospitals previously. It has been a few years, so, I admit that fully. But I think it’s just scale. While, I may have more resources today than I did 20 years ago working in a small community hospital. By percentage, I bet it’s the same. So, by numbers of FTE, for instance, it’s much more. But in terms of number of FTE compared to overall number of FTE for that organization I bet the percentage is pretty close. And I always thought innovate where you are, scrappy innovation, and you do what you can, you can carve out, you’ll figure out ways to carve out some dollars to do some transformational things and then you have to prove yourself. And I recall being in a small hospital back in rural Colorado and we had very limited dollars, but we took a risk. We spent some dollars in a couple progressive digital areas, if you will and we helped turnaround the revenue, the number of patients we were seeing, the amount of revenue of the organization. And we proved ourselves and then we got more money. So, I sort of challenged the assumption a little bit although I have deep respect for those who are in that situation and are trying to make a go of it with very limited resources. So, there’s no doubt that is another challenge. I think that what we’re seeing though, Paddy, is a lot of M&A and I think people are realizing the days of a one-off hospitals in today’s environment, given government reimbursement and where health care is headed is a very difficult task. And you’re seeing a lot of hospitals and we’ve purchased a few of those that are more rural that by themselves there’s no way they could compete. And by becoming part of a larger, more robust health system, it’s not only great for the community and the caregivers that work there but also the patients.

Paddy: Yeah yeah. Now I think that is true. And also, I think the good news is that there is a recognition that some of these capabilities that you have to invest in for a digital future are really critical for the survival of the organization. And it’s not just M&A but even in terms of the strategic priorities for the highest levels in the organization, I think there is some recognition that we have to make the investments for the future. It just can’t be business as usual. It’s not sustainable, especially as we shift from fee-for-service to a _______[unclear] model or a value-based care. So, switching topics again I want to go back to the question you mentioned about leadership in the pool, the people who come from the outside or whether they are from the inside. The kind capabilities, the kind of mindset and attitude they need to have to be successful in a collaborative environment. Now obviously digital transformation is not going to mean the same thing for everyone in your organization and many of your current talent pool will have to reskill themselves maybe with assistance from the organization. How are you looking at this maybe three, five years out? You know the technology landscape is going to look very different from what it is today. The business landscape and the modes of engagement with a patient, the modes of engagement between caregivers is also very different. What do you see as the strategic imperatives for your team and your talent pool in order to be prepared to transition seamlessly into the future?

Ed Marx: Yeah. The first one and I know this isn’t going to surprise you, but it might surprise others. My focus is really on passion and does an individual have passion of any sort and service passion in particular and then are they empathetic. It’s really about culture. If you have these things that are very difficult to teach. If you are passionate about what you do, and you want to be the very best database administrative for instance, or network engineer, that’s what you need or if you’re service like your heart is all about serving others. Those are things that are caught not taught, that are so important to success. Because you could have the 10 best database administrators that maybe are clock watchers and not all that interested in what they’re doing. What it means they have you know 10 let’s say average and who are passionate about they what they want to do, are service oriented, have deep care for our patients and providers they will outperform every time the others. So, we really look a lot to that. But the other things that we do is we have provided enormous amount of training. We train our people to make sure they understand the latest and greatest in training. What’s out there in terms of technology. We expose people, we have our own internal academy for business technology leadership where they’re exposed to more technology. We have rounding, everyone has to spend a day with a clinician where they’re exposed to. This helps both on the soft side that I spoke about but also the tech side they’re exposed to the technology where we are. And sometimes that helps create new ideas for technology what else we can do to make patients’ lives better, our caregivers lives better, outcomes better those sorts of things. And then hiring, as we talked about, hiring some team from the outside from other industries has proven effective. I recall you know we were trying to stand up enterprise analytics before it was as common as it is today. We knew payors were well ahead of providers at the time, so we hired that analytic leadership from a payer, and they set us on our proper direction very quickly. So, reaching out to other industries that have more strengths is really key. I think one final idea Paddy that I would have is that, we do these exchanges once a year, well literally two exchanges. One is with health care institution that we respect, the other is with a non-care healthcare institution that we respect. And we spend a whole day with our IT leadership team together and we compare notes. What technologies are you using? What are you seeing down the road? And then try to learn from them and how do they get training on that. How did they learn about what to do with it? So, there’s all sorts of methodologies. I don’t think there’s one specific one. But it’s really a matter of a healthy mix of all those things.

Paddy: Thank you. Ed, it’s been a real pleasure speaking with you again and you always have a fresh perspective on everything. I appreciate your coming back on the show and I look forward to catching up again soon. Thank you again.

Ed Marx: Thank you Paddy.

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