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 healthcare and technology talking about how they are driving change in their organizations.

Paddy: Hello again everyone and welcome back to my podcast. This is Paddy and it is my great privilege and honor to introduce my special guest for today, Nader Mherabi, CIO of NYU Langone Health in New York City. Nader, welcome to the podcast.

Nader: Thank you for having me.

Paddy: You’re most welcome. So, let’s get started. This podcast is mostly about healthcare digital transformation and I thought I’d get started with something at a high level on the current state of digital. So, healthcare is in the early stages of digital transformation and the definition of digital varies from health system to health system. How are you defining it at NYU Langone Health and how is digital different from traditional IT?

Nader: OK. So, let’s call it a back about, we have to put a context to digital transformation into what’s happening broadly in healthcare delivery space. Clearly, how healthcare delivery space is shifting from inpatient to ambulatory, home care, and preventive care, and the evolution of that is in the various degrees worldwide and also in the United States and different markets. But in an institution like us, which is over 150 years old, how do you transform it to really meet that challenge is an interesting question. And for us, that journey started about 13 years with our new Dean and CEO, Dr. Robert Grossman taking the helm of this institution and thinking holistically across the board about how that transformation would take place. Where the delivery of care is a standardized, uniform, and of the highest quality and then clearly has digital technology embedded to deliver that service. And to that end, digital transformation means taking an enterprise approach of how we do care delivery. And then leading into that delivery, technology that is integrated, smart, intelligent, and expands all the way touching the patient and their family. And the spectrum touches everybody that works and delivers that service across the board. You want to provide all-in-one healthcare service and we are that kind of organization. We want you to be connected with us whether you need us for very small things or all the way doing your life and then the very state of your health. And we are interested in your health and your well-being throughout your life. And digital plays an important part, as well as the space plays, where if you’re coming to ambulatory locations, you want not only the technology to work but you want the facility to work, you need the care to work, you want doctors to be great, and so on. So, in that spectrum that we feel digital transformation. How’s that different from traditional IT? It’s totally different. Traditional IT is about putting systems and making certain things work for people, but it’s not thought out about how it’s been part of an integrated delivery system. And it’s really critical and pivotal to the success of that transformation.

Paddy: Yeah, I think you touched on some very interesting points there. You obviously spoke about some of the big drivers for digital transformation. One of the big ones being the shift from inpatient care to ambulatory and home-based care. There’s one other thing you mentioned there which struck me, which was taking an enterprise approach to digital. But what we see in my firm’s research is that most health systems are driving digital as a portfolio of standalone projects, but they don’t necessarily align to some kind of an enterprise strategy or roadmap. Is that what you’re seeing as well, Nader? I just wanted to get your sense of what you see as the current state when it comes to these digital transformation initiatives.

Nader: So, I think there is a mix out there. I mean some of the institutes clearly see that as strategic enablement meant for delivering care. The other institutions see it as a one-off. But, to truly deliver digital services along with the rest of your capabilities, you’ll have to be thinking enterprise. You can be where, you’re looking digital to your patient and consumers but yet inside of the institution, everything sort of goes back to the dialogue mode. That just breaks the promise of digital, the cost savings, the integration, the quality that you need to deliver. Can you imagine if Amazon took your order and then from that point on they start the paper printed and then went into another system to process that and then if it was not integrated with the delivery side of the house, how your packages would get back to you and how Amazon knows to track that. It may work to some degree, but it’s totally a broken process that will be called Digital. For example, in our market, we have competitors who put out their virtual urgent care services but it’s not digital. It looks digital to patients when they get service. But the doctors on other EMR, the doctor may be servicing you from other states, the quality may vary. So, these are the things that I call is not digital. It may look like digital, but underneath it is all sorts of stuff that may create more work and to some degree impedes quality.

Paddy: Yeah. I will come back to the Amazon comment in a little bit. I did have a question for you on that, but I wanted to just touch on this one thing related to the shift from inpatient to virtual care or home-based care. NYU Langone Health is obviously sitting in one of the highest cost real estate in the world, is in New York City. Is there a significance to this shift that is either helping you or in some way impacting your approach to digitally transforming the enterprise, the fact that you are in New York City?

Nader: Well clearly everything, when you are in New York City, you have a different mandate, one we are in a highly competitive environment. In the New York City market, there are multiple competitors and they are very close to that location to each other. So, you don’t have to go far to find another healthcare provider to get your service, which I think keeps us on our toes. The second is that, we are for example, NYU Langone we don’t own a lot of hospitals. We only have hospitals that are really in the communion and close to you. So, our vision of how we provide services, we want it to be convenient to our patients and their family and close to your work or where you live. And then having ambulatory locations that are accessible as a multi-service specialty with imaging, all the convenience that the patients are looking for. And having that connectivity to our digital offerings so that you can feel that we are one click away. But we feel that the hospitals are needed where they have complex care, but they are very expensive resources to manage and we don’t have a lot of them. A lot of our care is really in the ambulatory where we have physician offices with multi-disciplinary specialty services.

Paddy: Yeah, that’s interesting. So, let me come back to the Amazon comment. We’ve been seeing the emergence of a lot of these what I call the digital front door applications if you will. Amazon is not the only one, Walgreens has launched something. In fact, they were on my podcast recently. We’ve seen Walmart launching something. We’ve also seen Best Buy making statements about getting into the whole business. So obviously they are all approaching it from their own standpoint. And then you’ve got the traditional health systems like NYU Langone and others that have a really strong connection with a community and a very strong brand image. But, at the same time, there is also a shift in terms of consumer preferences. Do you feel that there is a certain shift that means that the marketplace or the competitive environment is going to shift towards a whole different mode and means of acquiring and retaining patients? Can you comment on this trend, especially all these new non-traditional players getting in?

Nader: So, it depends on perspective. If you want to be just transactional, it’s one thing. Clearly, if I just want to see a virtual urgent doctor and just get my antibiotics or get treated and that’s it. It’s a different mandate where you want people to be connected with you, where you want them to think about you and their phone when they think about care. So, we think of much more of an integrated long-term perspective I suppose, to be totally transactional. So, we think that you feel that we are there for you when you need us and we are one click away from your phone, which most younger generation from early teens to 50s think now. So, it’s a broader spectrum and that we’re there with you in the long haul, not just a transaction.

Paddy: That’s well said.

Nader: Because we are capable of providing that full level of service. Our enterprise is capable providing that level of service. It’s a full service.

Paddy: That is true. So, switching tracks a little bit, as the CIO of NYU Langone Health, you have responsibility for maintaining your core transactional systems, but you also have a responsibility to drive the organization forward from digital initiatives and digital investment standpoint. Health systems carry a lot of technical debt and they’re generally considered to be a little bit of an under-invested in the technology landscape and a lot of the IT budgets from what I’ve seen and heard, get consumed in core platforms such as electronic health record system. They also have to invest in building for the future, even though that may or may not produce returns. Example being telehealth where I’m told no one’s really making money but you have to invest because it is the way of the future. How do you do the trade-offs in your role as a CIO?

Nader: So, couple of things, one I am very blessed that we have great leadership who really see IT, technology, and digital as a great enabler, not just an expense, but as really a foundational, enabler, and a strategic asset to propel the organization forward on its missions. The second thing is we’ve been very thoughtful about how to do this. So, for the past eight or nine years, we’ve been very focused on really fixing IT, the guts of technology and platform delivery and really curing it. As opposed to, you have a crumble building and you just want to build on that capability on top of it. So, we didn’t do that. We really were mindful of really fixing and fundamentally being platform-oriented and fixing all of that. So that when you moved to digital space, your foundation is not just totally rotten, and it will crumble. So, I will give you a concrete example, our virtual urgent care platform is really part of our EHR platform. The doctors don’t go to different systems to document the patient. They could clearly in the same chart, see their appointments whether that’s a virtual appointment or their regular appointments in one place. And the patient is engaged through the same app. So, that is an important aspect of really standardizing on platform, fixing the foundation and the data and the workflow, and really having the foundation of technology work and then that enables you to build on and create the digital capability. Now really the other thing, we’ve done is a lot of standardization of EHR across our enterprise. All our hospitals, all our ambulatory locations use one EHR, that’s okay, but use one common workflow and one common standardization, that is really what’s built on top of that. So, that you can assess the quality care we provide across the enterprise, not in one location or two locations. And the patient experience is the same whether you walk into our ambulatory location or a hospital in New York City or walk in Brooklyn or in Long Island you feel you experienced the same thing. So, these are foundational. That also allows to reduce the cost of technology services, so we’ll be able to maintain. We don’t spend all our IT dollars on EHR, to be very blunt. We don’t, Why? Because we’ve standardized so much and so we don’t have a lot of staff, an army of staff to maintain various workflows. So, we were able to use those dollars for other novel things such as improving patient or family experience through technology. I just want to make that point. If we are thoughtful about it, we actually don’t have to spend a lot of money on just EHRs. Now the implementation of EHR cost money again, I cannot deny that but that’s what we have to really not allow, standardization is the key. For example, we have one formulary, we have one supply chain item master.

Paddy: It sounds to me like you had a head start on this matter, Nader, because you mentioned that over the last several years, eight or nine years, you have been focusing on getting your IT, your core IT platforms standardized. And you’ve been investing progressively in that, so you don’t feel that you’re under-invested or unable to move forward with digital. So that’s a good place to be in. I also wanted to just ask you, so is your primary focus from a digital transformation standpoint. Is the primary focus really enhancing the patient experience or do you have other aspects? Can you talk a little bit about what may be your top two or three focus areas when it comes to digitally transforming the enterprise?

Nader: So clearly obviously, by far, most of our patients and their family , clearly because that’s who we serve. But no, it’s also how we can improve our clinician experience. So, we have another initiative that is really complementary about how we improve our physicians and nursing staff and other clinicians as part of that care. One of the things, we were very mindful when we did that and which go back to your question, it was siloed process. We didn’t want to improve the patients’ and families’ experience at the expense of the clinicians and make their life miserable. We were very thoughtful, and they are complementary. Same thing we want to improve our workforce experience. As you know a lot of work is instead mobile and people are mobile, how do we do that? Same thing for our scientists. How do we improve the researchers’ experience? We should be thinking through that. How we improve our students experience with medical students with academic and our own staff? So, when we mean digital, the focus is across the board. And I think there are all complementary. People expect a different type of service. But digital’s part again is a piece of how you move the organization forward to meet the challenge of the 21st century. So, it’s the space, it’s the quality, it’s the curriculum of medical education. So, the content matters and a lot of focus is given also to the content. For example, we have a three-year medical school track that we serve. How can you do that, because with the technology it enables you to do that. But we have to rewrite the entire curriculum, the medical education curriculum.

Paddy: Yeah, that’s well said. Now one of the big drivers and big enablers for digital initiatives is data and advanced insights. Aggregating and analyzing data and healthcare content has got some challenges. Some are historical – data quality, data silos – but also interoperability issues and so on. Can you talk to us a little bit about how you’re approaching data governance and really harnessing all the data that you have to drive some of the digital experiences that you’re building?

Nader: So, let me go back again 10 years ago when we were going through that journey and now it’s eleven years. So, I have been involved in a lot of data warehousing projects and data analysis throughout my career. And one of the things that I learned and with my team from the beginning, we knew that we are going to a journey and really standardizing a platform and getting out all the pipes and reconnecting things in a meaningful way. So, we set up some free guiding principles about the data because we knew in order to upgrade analytics you have to get the data right. As you know, in old traditional data housing projects and still people do it, how many pieces of data gets mapped and translate into the data warehouse ETL tools, which I’m sure exists in every institution. One of the guiding principles, we say that, if the data quality is not there, we will fix that at the source. We refrain from mapping the data in the data warehouse in the analytics layer. So, being the CIO of the place and having control of all the systems, this one guiding principle, we did the hard work. So, we went and said, we were going to fix the transactional system about the data, we’re not going to map it. So instead, in my organization, people don’t map the data, people fix the transactional source. It’s hard to work but when you do it then the data quality gets better. Second about data quality, you have to put in the hands of people to see it and make it visual so people could use it. So that’s how quality gets better. Right. I mean this is written about this in many places. If the data is hidden, it’s not visualized then the quality is not going to improve. Because when people see the data and say wow what’s this? Was this really the amount or is that really the length of stay number? That doesn’t quite make sense. Then people want to go fix the source. People are going to really focus and then you take it out of that equation and then what’s left is really the real thing. When you want to act, when you see what’s happening in an enterprise whether that’s clinical care or corporate. And people say now I believe in data and believe in quality, this is what’s really telling me, what do I do about it. And that’s the other part, what do you do about it? Which is also an interesting part where what kind of data and insight can you provide that’s actionable. And so, you have to be mindful of that about how do you make the data actionable. And it doesn’t do any good if I show your data that’s three months old. It may be nice to know; it gives you some perspective. But it’s hard to take action on a three-month-old data or sometimes from last 24 hours data, depends on what we’re trying to do. So, these are the foundational things people think you have to think through. And we thought about that 10 years ago and that was the big dividend for us. Now that we have 700 metrics and 83 dashboards and we continue investing in data analytics, AI, and so forth but I’ll stop there.

Paddy: Yeah. Well, let’s talk about AI since you brought it up. What is the current state of AI? There’s a lot of talk about the promise and the potential but also a lot of concern about how it might be used unintentionally, harmful or discriminatory ways. What is your take on that?

Nader: Well, clearly, we see the use of NLP, predictive analytics and AI in a way that we think that it’s helpful, depends on what you want to do with it. A lot of people focus on putting AI in the highest end of the spectrum in terms of predicting mortality, which we do some of that. We’re giving it to their highest level of work, which is in our cases, clinicians, they’re highly intelligent, they practice. So, we think that helps them in a great way. But also, we really think that AI can be implemented at the other assets and we can help others to give better insights so people can do their job better. We don’t think AI is at the point where it’s going to cure cancer but it’s clearly a capability that helps people make their decision better, for us, it is across the spectrum. We also see some utility for that across very low hanging fruit things where it really can bring to fruition some things that are very mundane and provide good insight for people to do and we can reap the benefit of that. So, we see it being applied across the board, but we don’t see that as being the panacea that it would automatically cure the patients, and everything run on their own and AI would drive everything. But it’s very helpful when you highlight where a patient could be at risk for heart failure and alert the heart failure team. So, there are other things that are clearly complementary, scanning things and bringing insight to things.

Paddy: Yes certainly it looks like AI has made a great deal of progress in certain areas specifically images, you mentioned scanning. But there are other areas like cancer, oncology where no one’s going to turn over a diagnostic or a treatment decision to AI tool anytime soon. But yeah, I get your point as well. Well said. So, we’re coming up close to the end of our time. I do something called a lightning round where I mention a few terms that relate to emerging technologies in healthcare. I’d love to get top of the mind thoughts on those terms. So, we’re ready for this?

Nader: Sure.

Paddy: Okay. Here we go, Cloud.

Nader: Okay. Well, you can’t avoid it, that’s for sure. It’s always going to rain someplace. We know that our clouds are important. You have to be very mindful of that. I can see in the healthcare industry ourselves; we will be in multi-tenant cloud there is not going to be one cloud that we will be residing. So, you have to approach it in a very programmatic way. There has to be ROI for a cloud. To do that, you have to really make sure that you orchestrate your cloud strategy. So, you can’t leave this strategy, the orchestration to others. You, the institution has to do it in a thoughtful and careful and calculated way. And you have to be very calculated about how you move yourself to the cloud. That gives your users, your patients, your institution the best value.

Paddy: Okay. Next one, voice recognition.

Nader: Well, I’m surprised you didn’t put voice recognition with AI. I mean what is voice recognition without an NLP and AI. Right. So, I think to combine, and here’s what, AI and NLP and all these tools play a great deal. We think it’s a game changer for our clinicians that could make an impact, improving their lives. If it’s done in a way that is integrated, for example, we do try our clinicians use voice recognition on top of our EHR, just great potential. I’m optimistic about this technology combined with NLP and AI on top of an EHR that is truly integrated. And hopefully, at some point, this technology would take away the keyboard and mouse. And also, with the video. So, it’s just not by itself, I think with video, with NLP, with integration with EHR to the point where the mouse and keyboard. And there are firms that already have a prototype working. Where you now talk to a patient face-to-face and the EHR is around you with a video, with a voice, with the computer screen and so forth. So, I’m very optimistic about that.

Paddy: Yeah, that’s great. Automation and RPA (robotic process automation).

Nader: I would say that, first, you should have a good enterprise strategy. This is where I think people kind of do that in small niches. And sometimes people buy multiple RPA tools, which is okay, because it’s in the technology. But given the technology that is highly regulated, there are so many steps to follow and paths to meet all sorts of regulatory requirements and billing and so forth. I think it’s a good play, especially in the backend office, even helping clinicians to work their queues about mundane things that they can move around to lighten up their day. So, there’s a good play for cost savings and reducing the burdens on those workforces.¬

Paddy: Yeah, I see this being used a lot in the RCM space. Do you think that’s a good candidate for the prime candidate today?

Nader: I think so but there are other spaces as well. I said that just like a physician work queue. There are a lot of mundane things that comes on and a physician work queue. They complain to me about staying after hours to clean a list. Then maybe an RPA tool can prioritize and move things around and channel those tasks to others. So, there’s a good play in other spaces as well. So, I’m open minded about it. I’m open-minded about that. It could be applied in many places. I think if you talk in terms of Wall Street, I’m bullish on it.

Paddy: Yeah. I agree with you. Yeah. Any anything that reduces ‘pajama time’ as they say. It’s great. All right. The last one on the list is AR/ VR, extended reality.

Nader: Again, you mentioned the AR/VR but you’re not mentioning 5G. So that’s another fastening space, I think is a much longer-term to be very honest. As you know right now, AR/VR, people are using as teaching tools, as things that we can simulate. For example, in healthcare and education, you can teach medical students or a resident about surgery techniques. So, I think right off the bat, today, it’s a great teaching tool. But also, a good patient education tool but the devices are still heavy, they weigh a lot and cost a lot. Think about how you can teach a patient or their family about a procedure that he can see it. Again. Good teaching, it’s there, cost has to get cheaper. But you can imagine that someone with 5G actually visualizes and do robotic surgery from a remote corner of the world. That’s kind of interesting when you combine these with a reliable remote network and be able to feel and touch things in a different way.

Paddy: So, are you piloting 5G at NYU Langone health?

Nader: Not yet. We have, some of our wireless access points are turned on for 5G. We are experimenting a little bit here, but I like to scale things once we expect to be across the board because that’s where you realize the benefits right. When you all are or are connected in different ways. So, to realize, you have to have it enterprise-wide. Otherwise, it’s just, when it’s isolated that you don’t reap the benefit in a meaningful way.

Paddy: Yeah well, one thing I did want to mention for the benefit of all listeners. You have a very interesting Medium page where you talk about some of these initiatives. And I’ve read some of those blogs, they are very interesting, you share with the public at large. Some of the initiatives that you’re working on, so people can look at and understand how you’re thinking about some of these emerging technologies as well. I just wanted to give a shout out because I haven’t seen many others do this and I think it’s great that you’re sharing some of this information in a public forum.

Nader: That’s great. And I appreciate the comment, I think my team has done a great job of really putting that together. So, I’m sort of acting as chief editor. Really the articles, most articles are written by my team. They write and our faculty by large. So, one of the guiding principles we had for our medium. What I wanted to put there are things that are useful, that are highest quality, that give people perspective but not bombard people with all sorts of stuff. So, we are being very thoughtful about what we put there and we share as much as we can but with quality. I think quality is important because there’s so much out there and I think public and our colleagues really need something that they trust in and this with quality.

Paddy: I certainly see that and I have read through several of the blogs. So, anyway, we’re almost at the end of our time here and I just had one last question for you. You’re in New York City. You worked in your past in the banking securities industry and so on. How is healthcare different from other sectors when it comes to digital transformation, technology wise? What advice do you have for tech firms and digital health innovators who are looking to serve the needs of NYU Langone or others like you?

Nader: Well clearly, there some technologies, there is a lot of commonality in terms of how you organize technology. For institution, how do you create governance? But on the other hand, healthcare in is its uniqueness. One of the advices I have which I’ve learned, also the hard way that, transaction in healthcare is very complex. Think about, by the time you think of seeing a clinician and how many transactional interactions you would have by the time you actually in the exam room or buy the medication. Think about a banking transaction whereby, you want to buy securities or replace an option. It’s a very simple, binary transaction compared to the amount of data is being collected just for you to make an appointment to see a doctor. So, in healthcare one of the advices I have is, be very mindful about because healthcare transactional is multi-touch, complex, not that cannot be solved through visual means and optimize. But there’s complexity that you have to be aware, it’s not as black and white as banking transactions for example.

Paddy: Very well said. Well Nader, thank you so much for your time. It’s been a pleasure speaking with you. And thank you be sharing all those insights.

Paddy: We look forward to staying in touch.

Nader: Thank you. My pleasure.

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