Month: November 2019

Health begins where we live, work, play, pray

Episode #29

Podcast with Steve Miff, Chief Executive Officer, Parkland Center for Clinical Innovation

"Health begins where we live, work, play, pray"

paddy Hosted by Paddy Padmanabhan

In this episode, Steve Miff discusses how Parkland Center for Clinical Innovation (PCCI), a non-profit organization, has developed advanced machine learning algorithms to understand the role of social determinants of health in vulnerable and under-served communities.

PCCI operates with the assumption that health begins “where we live, work, play, and pray.’ The key aspects of PCCI’s journey have always been to partner with organizations, locally and nationally, who share the same goal and understanding. Steve discusses the success they have had in improving the lives of their communities and reducing the costs of care through their machine learning-based approach. He highlights the importance of a robust data management and infrastructure environment for success with predictive and prescriptive analytics in healthcare.

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. This is Paddy. And welcome back to my podcast. It is my great privilege and honor to introduce my special guest today, Steve Miff, Chief Executive Officer of the Parkland Center for Clinical Innovation. Steve, thank you for joining us and welcome to the show.

Steve: Thank you so much for having me.

Paddy: You’re most welcome. So, Steve tell us how the PCCI came about and your affiliation with Parkland Hospitals.

Steve: Yeah, it’s actually a fantastic story. PCCI started as a department within Parkland back in 2010 with the goal of starting to really look at readmissions and trying to understand the role that social determinants of health and particularly housing instability were playing into the individuals and patients that the parkland was serving. And in 2012, there was the realization that an organization like PCCI would much better operate outside the direct walls of the healthcare system. So PCCI was spun off into an independent, separate non-profit organization that’s still affiliated to Parkland through our board. So, the goal was to not only be able to continue to work with Parkland and the community that Parkland serves, but also enable the organization to reach out and collaborate, partner work with other organizations locally and nationally. So, that was the start of really what I consider to be PCCI. And one other I think really important development in our journey has been that since 2012 we started to build the various models using data science and applying it to social determinants of health and programs and realized that the number of those models had much broad application and commercial value in the marketplace. So, instead of forcing PCCI to be also that commercial entity, we spun off a separate company in 2015 called Pieces Technologies with a completely different company, venture-backed, different structure, leadership, et cetera. But created an exclusive licensing agreement between the IP that PCCI has developed and will continue to develop to license it to a startup organization that can commercialize that expanded, bring it to the broader market in PCCI would continue to be innovation early-stage R&D type of organization, but benefits from those commercial activities. So, I think that’s also kind of adds to our journey, adds to our story. And I think it’s a really important piece of not only our history but how we’re looking to expand and succeed in the future.

Paddy: Yeah. That’s an interesting background. Actually, it’s a very interesting structure that you just described. And of course, PCCI and Parkland Hospital is based in Dallas. And so, I imagine your focus, at least for the near term, is mostly in and around the Dallas area.

Steve: It’s been in Dallas and we’ve continued to expand and work with other entities beyond Parkland in the DFW area. But over the last twelve months, and this is something that’s going to continue moving forward. We’re expanding our partnerships with other organizations across the country and focusing on really staying true to our strengths and mission on applying data science and social determinants of health to those vulnerable individuals and populations, but also be able to partner with organizations to build, test, deploy some of these models in newer and different geographies. I think having that opportunity to really understand how some of the things that are working locally can be adapted in other geographies with similar populations. It’s a key part of our journey and we’ve already started on that.

Paddy: Right. And I’ll come back to that further on in the conversation. PCCI’s focus seems to be on underserved communities. I think you alluded to that in your earlier comments, especially focusing on leveraging social determinants of health to serve underserved communities. Can you maybe give us an example for our listeners to understand how or take any project or initiative where you have used social determinants and your internal capabilities with data sciences and model building and so on to demonstrate positive outcomes for your community?

Steve: No, absolutely. And you are so right. You know, I called sort of the PCCI genius that happens when three things come together. One, that our ability to leverage our data science in AI, machine learning, cognitive computing capabilities apply that to social determinants of health for the high risk, vulnerable populations. And I think a great example of how all those things come together is being focusing on one of the very critical populations that are impacted by socioeconomic status and conditions. And that’s the work in looking at pregnant women who are at risk for preterm birth. And as we’ve really focused on that population, I believe there are three key things that needs to come together for that to be effective. One is to be able to understand the risks so that risk stratification becomes critically important to understand the profile of an individual. So, we can tailor the interventions and engage individuals based on their needs and risk. So, don’t treat each person the same. Number two is to connect individuals to services. What I mean by that is making it easy, make it accessible for individuals to be able to understand not only their risk but understand the options they have available and make those options easily accessible. And number three is also engaged individual directly. We need to and have seen great results in not only connecting providers with the broader community to support those individuals, been engaging individuals themselves, but do that in a customized way based on their needs and risks. So, as we started on this journey, we took the social determinants of health and that became a key predictor in the model. But it was done in a way that we quickly learned that is only powerful when it’s specific enough. And to get it specific enough, you either have to survey, collect information directly from an individual, or use information about the environment, about the neighborhood to understand that local social-economic challenges and then need to be done at the block level, not at the zip code level. So, as we go through that, the journey 12 months results, we risk stratify over 26000 women enrolled over 800 of them into the program. And a key feature of that was a text messaging program to remind them about their doctor’s appointment, provide nutritional tips and other patients’ specific messages. What’s really the main goal was to tailor those and increase prenatal attendance. So, as the old metrics I mentioned, but also pharmacy claims were some of the metrics that went into developing the machine learning-driven predictive model to identify risk-stratified pregnant women. The model included over a hundred and ten features that were contributing to preterm birth, things such as housing, stability, nutrition, nicotine, and alcohol use, whether it’s medical comorbidity, apathetic history, etc. And a one-year pilot we’re actually not only pleased but a bit surprised at how effective it was. We saw over a 24 percent increase in prenatal visit attendance among the women receiving the text messages, and that resulted in over 27 percent reduction in preterm birth at less than 35 weeks of gestation. And that contributed to an over 54 percent decrease in baby costs per member per month. So, you know, sometimes some of these problems are hard to get off the ground and you don’t typically see a ton of results in the first six to 12 months. So, we were particularly pleased to see these fantastic results.

Paddy: So if you were to boil this all down to maybe the one or two big variables that have a very strong correlation towards improved outcomes in terms of everything you described, it is mortalities and increased health for the mother and the baby and so on. What are the one or two that you based on your work of come up with as the most important predictors?

Steve: Yes, absolutely. So certainly, medical history, including the pharmacy utilization and the number three social determinants of health, are the three key elements. But again, the social determinants of health only became part of the top three predictors when that information was specific enough at the block level when it was initially modeled at the zip code level. The social determinants of health factors were outside of the top 10.

Paddy: So social determinants of health are now a big topic. And different people are focusing on different aspects of social determinants. So, as an example, and I’ve heard this being said that a zip code is probably the single biggest determinant of health outcomes for a community. On the other hand, we also hear things about food deserts and transportation deserts. Now we’ve seen Uber and Lyft and all these companies forming partnerships with electronic health record vendors to include the option to actually offer free rides to people who do not have access to transportation as an example. So, when you talk about social determinants, what are the one or two things that for your community that come up with the surface as important ones?

Steve: So, each community varies in our community. What we tend to see is that access to nutritious food tends to be the highest and most prevalent need, followed closely by transportation and housing. However, Paddy, what I will tell you is that we’ve studied this extensively and as we’ve looked at the needs of individuals, not just the primary need, but on average individuals that have one social determinant of health need, they have about 2.5 total needs. So, what I think it’s really important as we talk about these is not only addressing the primary need but concurrently addressing some of those other correlated needs as well. So, that’s one of the key things that I think it’s important to really understand and create an ecosystem and a connected community where these things not only are being understood, but an infrastructure to be able to connect individuals to those services. So, they receive assistance not only for food but equal, like you said, for transportation, for housing, utilities, daycare. And the list goes on and on. But don’t just look at one look at collectively for the comprehensive needs of an individual.

Paddy: So, tell us a little bit about your data sources. Where do you get the data from and what does the data management infrastructure look like?

Steve: Yeah, that’s one of the key things that oftentimes are not talked about a lot because we always jump into the fun part, which is sort of like with our social determinants, all the machine learning. But without the right data and the right infrastructure to be able to manage that data, you can’t really do anything. And I’ll go back to the point that I’ve made earlier, that for us, we have a strong belief and we operate under this principle that health begins where we live, work, play pray. Basically, what we spend our time. It doesn’t begin in our acute care facilities. So, what that translates it from a data perspective is a need to comprehensively understand individuals and digitize that information about not only their healthcare and their health history but information about their life, information about their neighborhood, information about their environment. And I’ll give you some specific examples. But in addition to that digital data, we’re also trying to understand qualitatively the behavioral sciences, also the choices that individuals have to be able to then influence the choices that they make and also better understand the context about their self-capabilities, resources, challenges and some of the things that are starting to be called around learned helplessness, which gets into even one service available, understanding why an individual may not be leveraging and utilizing those. So along with saying that digital information and then qualitative information really important. So, from digital information, I mentioned that we need to understand three key things in their healthcare, including mental behavior health and health history. Information about the neighborhoods and that individual life and bring together those. So, for example, for the healthcare data, the opportunity and the ability to ingest not only claims from whether it’s health plans, state HIS, local HIEs, but equally data from the electronic health records. For that environment be able to ingest and leverage data from local municipalities, whether they’re 311 system 911, as well as data and information from community-based organizations. And increasingly, because so much of the care is transitioning to home, is in just data from IoT devices as well as mobile communication devices. So, a lot of data. Right. And it’s all in different sources. So, then the technology footprint needs to be able to accommodate that. We actually look at licensing that from somebody else. We did that for a short period of time, but quickly realized that there was not really conducive to innovative R&D work that we are doing for actually ended up over the last two and a half years building our own infrastructure in partnership and leveraging the Microsoft Azure cloud environment and their five critical areas that I see and we have seen, they’re really important to be able to manage this. One is secure, encrypted connectivity and point to be able to accommodate the ingestion of all those data sources that I mentioned anywhere from using APIs or fire APIs as SFTPs or databases. In some cases, we just need to ingest spreadsheets because that’s the information that a community-based organization has. You need to have a data engineering and orchestration engine to be able to bring all that information together, align it, fill in the missing data, etc. The fun part is that machine learning-based predictive model environment. What we’ve decided that’s really important is to use as many open source modalities available because that facilitates better knowledge transfer and facilitates much better code creation. But then you need to have a data persistence framework. You also need to have a data dashboarding, reporting framework to be able to accommodate the end-user modalities. And finally, the fifth thing is security and access control. So that kind of spans all of those different things. So complex because of the type of information that needs to come together. But also, I believe it needs to be done in a way that again, facilitates that knowledge transfer and facilitates co-creation because it’s such an emerging space.

Paddy: And that’s, of course, the perfect segue for us to talk about the models themselves and your whole process of developing your own proprietary models or tapping into models that are available as part of your share learning platform. There’s obviously a big opportunity to improve healthcare outcomes through predictive analytics through AI, machine learning, whatever you want to call it. But there is a flip side to this as well and AI has been getting a little bit of attention of late for some of the unintended downsides or consequences, if you will, such as unintended bias. There was one example that was recently quoted in the papers where it was one of the big companies whose models were found to systematically discriminate against certain members of the population. These black-box algorithms are people don’t understand them. And in many cases, it’s not even revealed to them. So, there’s a lot of complex issues around it. Can you help unpack where we are in terms of accepting AI models as important and necessary inputs for improved care delivery? And what should we be cautious about?

Steve: Great. Great question. And you’re so right that there’s been so much attention and AI has become such a buzzword that it feels like everybody says they’re doing it. And as soon as they put it on their portfolio, their valuation goes up tenfold. But I think one of the challenges has been that it’s not being applied or measured than the results have not quite been there. And I believe that there are three key things that need to happen in order for AI to be meaningful given the space that we are on today. One, it needs to be scientifically sound and physician tested. And what I mean by that is the discipline and the rigor around the statistical analysis, the modeling, as well as clinical input into the parameters of the models need to be really sound. And that information needs to be very transparent. That’s not the place to be proprietary. Number two, and you already talked about it. It cannot be a black box. And that black box is not only just the scientific component to it but how it’s being used. You cannot just generate a risk score that tells somebody, hey, this is a high-risk patient without being able to give that individual the reason or the top features that are contributing to that risk. Because by giving those insights from that model, it starts to enable individuals to better understand what’s contributing to that risk and gives them a start where to explore further for better understanding and for action. It actually kind of takes it from just being a predicting model to what I’ll call a prescriptive because you started to prescribe where to actually look next. And the third critical component, which I think has really been missing and we’ve been focusing a lot on, is how do you seamlessly embed any AI or machine learning type model within existing workflows? You cannot expect individuals to use them if they have to go outside of where they’re already doing their work. So, whether that means directly into the electronic medical records or within the workflows of a community based. the organization, the volunteers, etc., But that needs to be a pretty critical component to it. So those three things I think are critical. I think one of the other things, Paddy is that we have been talking about AI and machine learning as this one thing without a lot of attention. When you think about models that not all is the same. And what I mean by that, I tend to think about three different categories. One is more of the supervised time type of methods where we learn to known patterns. I think, you know, anybody that’s doing AI probably knows the majority of models are in that space, you know, takes label input data predicts outcomes. Future things like sepsis models etc., fall in that category. The second bucket is that unsupervised methods ______ [unclear audio] and unknown patterns of much few organizations are doing that. That takes unlabeled input data finds hidden patterns, things such as clustering, or patients like _______ [unclear audio] of analysis falls onto those type of methods. And finally, it’s sort of the whole reinforcement type of models where actually you generate data. So, you take label input data interacts with the environment, learn series of action and starts to actually generate the data. So that’s more of the action derived rewards that are whether it’s chemotherapy, clinical trial, dosing, regiments, election, etc. So, I think folks need to understand that it’s not all the same. You need to really apply the right model to the right area. And also, be thoughtful about what are you applying these in healthcare because there are different applications, whether you’re talking about safety or quality, whether you talk about drug discovery, therapy, diagnostics, administrative, etc.

Paddy: Yeah, you’re probably aware that the FDA is also trying to bring about some they’re proposing some kind of regulation around some of these algorithms so that there is a degree of transparency around what actually goes towards determining the predictors and using them in care pathways and treatment protocols, but also whether there are any changes. There is some kind of a log or trail or some kind of a compliance process in place that helps people understand what change in the input and therefore, what kind of output can work. Quickly do you have any thoughts on that? Are you a part of the process? Are you working with the FDA by any chance?

Steve: No, I am not working with the FDA. We’re actually working closely with CMS and CMMI and I’ve been participating and listening sessions as they’re thinking future models and applications. But no, I have not to date work with the FDA on this.

Paddy: OK, the work that you’re doing is very complex, very advanced. And of course, it requires talent of a certain caliber and data scientists are hard to find and even harder to keep. How do you manage that?

Steve: Yeah, I am always struggling with that because it’s interesting. That’s actually significantly accelerated. It’s been more challenging over the last 18 months. It was before. But the competition for talent in this space and its not just within healthcare, it’s across all sectors. It’s really been difficult and it’s intensified. So, we’re right in the middle of it and we’re focusing honestly on three key things and that’s sort of proven to be somewhat successful. One, we sell our mission and that’s around the opportunity to apply this to help the most vulnerable within a non-profit type of environment while operating within a structure and a similar culture to a technology startup. So, sort of that dichotomy between the application of the work being really close to the impact of the work but having the capabilities of a technology startup very impactful and resonates with individuals. Number two, we actually sell to candidates access to our data and access to and the makeup of our team. So we feel and Dick Daniels, who is the Chief Information Officer for Kaiser Permanente and who is on our board, constantly reminds us that we have unprecedented access to data, not only through the relation that we have with Parkland but with the local Medicaid plan, the local HIE so and the local community. So, we have real-time access and pipelines created to be able to use patient-level data, to be able to build, test, deploy these models. So, we sell that because oftentimes that’s one of the barriers and any geek and data scientist that’s meaningful to them. We sell the team because I think the size of the team is meaningful as well. We have over 10 data scientists led by Vikas Chowdhry, who was the Head of data science for Epic and build that team. We have a very diverse group, so being part of a learning group of peers, it’s something that we focus a lot. And, you know and finally, we have actually started to create our own pipeline and what we’ve done internships in the past. We’ve created a much stronger focus on that. And for example, this past summer, we launch a much more formal internship program that focused on advancing women in data science. And we had seven summer interns. Obviously, all females. So, we took and respond that we did it in partnership with the statistics department at SMU here locally. And it’s been extremely successful. And something that we’re going to be looking to continue moving forward. So, we’re sort of trying to create our own talent pipeline and actually ended up hiring one of those individuals out of this summer program. Something will help is going to continue.

Paddy: Fascinating. Well, Steve, you’ve got some very interesting things going on. And I want to thank you for sharing some of that with me and our listeners. And I really look forward to following your work and PCCI in the coming months and years. All the way best on your mission. And once again, thank you for joining us and being on this podcast.

Steve: Paddy, thank you so much. It’s been a pleasure. And I continue to look forward to learning from your podcast because they are excellent and always very informative.

David: Paddy, thank you very much. Been a pleasure to talk to you today.

We hope you enjoyed this podcast subscribe to our podcast series at www.thebigunlock.com and write to us at info@thebigunlock.com

About our guest

Dr. Steve Miff is the President and CEO of PCCI, a leading, non-profit, artificial intelligence and cognitive computing organization. Before joining PCCI, Dr. Miff served as the General Manager at Sg2, a national advanced analytics and consulting business serving over 1,200 leading healthcare systems. He led the organization’s strategy, operations and growth, and had overall P&L responsibility for the $55M+ business. Dr. Miff also led Sg2’s merger and integration during the VHA, MedAssets and Sg2 acquisition. Prior to Sg2, he was the Senior Vice President of clinical strategy, population health, and performance management at VHA (Vizient Inc.). Dr. Miff was a member of the senior management team and the executive oversight committee. His role with VHA included P&L responsibility across seven national business units with a total of over $25 million in revenue. Dr. Miff launched and grew three new enterprise businesses, led the development and rollout of several key strategic partnerships/acquisitions, and was a senior member of the integration team for the VHA, UHC, and Novation merger. Prior to VHA, Dr. Miff served in various roles at the Rehabilitation Institute of Chicago, National Institute of Standards and Technology, and St. Agnes Hospital System.

Dr. Miff earned his PhD and MS degrees in biomedical engineering and a BA in economics from Northwestern University. He has been an adjunct professor of biomedical engineering for more than five years and has authored more than 100 thought leadership, white papers, and peer-reviewed publications. He has served on the Senior Board of Examiners for the Baldrige National Quality Program and on the Executive Quest for Quality Prize Board Committee for the American Hospital Association. He serves on multiple boards, including DFWHCF, NurseGrid and SMU Big Data Advisory Board. Dr. Miff was The Community Council of Dallas’ 2017 Social Innovator of the Year award recipient and a finalist for the 2019 Dallas Business Journal most admired healthcare CEO award. Under his leadership, PCCI was awarded the 2019 Best Tech Startups in Dallas by the Tech Tribune.

About the host

Paddy Padmanabhan is a widely published and quoted thought leader on digital transformation in healthcare. He is the author of The Big Unlock: Harnessing Data and Growing Digital Health Businesses in a Value-Based Care Era, and the CEO of Damo Consulting Inc, a digital transformation and growth advisory firm based in Chicago.

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Successful organizations put patients first and everything else follows

Episode #28

Podcast with David Quirke, Chief Information Officer, Inova Health System

"Successful organizations put patients first and everything else follows"

paddy Hosted by Paddy Padmanabhan

David Quirke, Chief Information Officer at Inova Health System, discusses his new role, their technology environment, high-level priorities, and the mission to provide world-class healthcare with every patient interaction.

According to David, successful organizations always put patients, quality, and the outcomes first and everything else follows. Technology at Inova is taken as an enabler to the patient experience. Inova Health’s approach to patient experience and digital transformation is focused on a suite of technologies rather than focusing on a specific technology.

David shares his thoughts on building high reliability within information technology and how the underlying infrastructure is a critical enabler for digital health solutions.

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 today, David Quirke, newly appointed CIO for Inova Health System in Northern Virginia. David, thank you so much for joining us and welcome to the show.

David: Paddy, thank you for having me. It’s a great pleasure and honor to be talking with you today.

Paddy: Thank you. So, you’ve recently come on board as CIO for Inova Health System. Can you share a little bit about your technology environment and your high-level priorities in the near-term?

David: Sure, I will be happy to do so. I am very newly minted in the role, this is week number four for me, but I’m happy to share what I’ve uncovered in the last three and a half weeks. In terms of technology like many organizations, we’re a core EMR platform, the Epic platform. We’re in the middle of a large ERP, enterprise resource planning, deployment across the organization. In terms of our PACS systems, we have our core PACS on the cardiology system focused around Fuji. But really in terms of our priorities in technology, they’re exactly the same as the priorities of the rest of the organization. Our mission to provide world-class healthcare every time, every touch, in every community, we have the privilege to serve our very thoughtful words in terms of how we’ve created our mission. And really, when we look within the technology infrastructure on platform, we leverage the exact same goals and mission in terms of how we operate and organize our information technology journey. Like many organizations is towards a service line model and a clinical enterprise. So, within IT, we’re on that journey too, in terms of how we evolve from the facility-based system model to really as we look at the various different service lines. How do we need to evolve as a service component to that to support a new service line model, which is essentially a triad model, where we have a clinical leadership, a nursing leadership, and an administrative leadership really driving systemness commonality throughout the organization. The themes that we talk about as a system within IT really revolve around evolving to a systemness model. So, when we talk about every touch, every time, wherever one of our community members interact with an Inova caregiver, there’s that system. There’s some commonality of service everywhere we go. Within IT that customer focuses our customers being the full community of patients, we have the privilege to serve and the customers, which are all the caregivers that go into supporting that care model. High reliability within information technology and the health system is a theme. It’s challenging to drive a high-reliability organization without a high-reliability infrastructure beneath it. Fiscal acumen is something we all in health care have to be conscious of. And that model of fiscal document relating to value is something that we’re very consciously aware of. Then research and innovation are at the core of all we do. We are absolutely focused on looking at research and innovation that will have direct, tangible impacts on the care models that we’ve built.

Paddy: Thank you for that background. And we will unpack a little bit more of that as we go through the conversation. So, let me jump right away into a couple of points that you made. One was around the consumer focus and the other one was around reliability in terms of all the infrastructure, because you can’t really drive better experiences and so unless you have a reliable infrastructure that enables you to deliver that experience, so many people refer to what is known as digital transformation today. Many of the things that you referred to are actually components of what I hear as digital transformation when I talk to other health systems. The focus area, at least as far as all the research that we’ve done in my firm, is clearly on the patient engagement and following that closely behind is also the caregiver experience and the caregiver enabled so that they can be productive and effective. So, can you talk to us a little bit about what you’re doing specifically in terms of the patient experience and the patient engagement aspects? We see a lot of health systems launching patient apps, digital front doors, as they’ve been called, in a very generic way. Can you talk to us a little bit about what you’re doing in that regard?

David: Absolutely. In general terms, our approach to the patient experience of digital transformation is really not focused around a particular technology, but really a suite of technologies. And rather than looking at how we deploy telehealth, how we do our digital front door, we really want to think in terms of the patient experience and their caregiver experience. To that end, when we think about terms like reimagining primary care, breaking down in a kind of lean like model, understanding the touchpoints on how we deliver primary care from that front door app through to allowing, through to arrival, through to rooming, through to ordering results that the visit, the post-visit. And rather than look at a specific technology and how we’re gonna deploy it, we really want to leverage how we want that experience to be for our patients and for our caregivers and really look at technology as just the enabler, not for its own sake. So the example being, you know, as we look at our front door, as we look at rivals looking at geolocation, looking at how we welcome, how we greet the patient with equipping the caregivers with the right technology, how we room the patient, how we engage the patient during that visit, how we make the EMR more passive in that way rather than at the forefront. You know, the analogy of the caregiver trying to keep up on the keyboard as the patient is working through the components of the visit. We want to look at technologies where the EMR becomes a vital but more passive element of that and really is an enabler in terms of the care model. So, we’re excited looking at technologies where those passive listening. There have been some recent announcements that we’re excited about exploring in that model. And the concept of the provider being bent over a keyboard and not a perceived to be attentive to the patient’s needs is something we really want to explore and how we add value to that visit and make the process of gathering data, presenting data in a much more passive way rather than look at a particular technology. How well do we really want to break down the experience from a patient first perspective and make sure that the technologies that we’re deploying and looking to deploy really facilitate a much smoother experience for both the patient and the caregiver.

Paddy: Just on that point of making the EHR systems more usable, more passive, obviously everybody talks about the huge burden that’s come down on caregivers because of the digitization of medical records, which was necessary. But at the same time, it’s had some unintended consequences. So, can you just talk a little bit about one or two specific things you’ve done to make the EMR systems more usable and give some time back to caregivers because that seems to be one of the big issues?

David [00:08:21] Right. One of the things that we’re exploring right now is in the acute care setting we have, I’ll use the term system to talk about all the components of a system, not a specific system. All our caregivers have a badge with an identity component that has the ability for us to identify that caregiver. We have systems that identify the patients that we have in every room. We have computers in rooms that know where the patients are. And we have wireless technology that can inform of movement and location. Yet when a caregiver viewed a nurse, med administration, or a hospital is surrounding. Today still have to go from device to device to device, almost in a muscle memory model bouncing from screen to screen. So, we’re right now interested in exploring technologies that combine a variety of systems to facilitate care. So, for example, if I’m a nurse and it’s 3 o’clock in the afternoon and it’s med admin time, why can’t the systems know that I’m Nurse Quirke? Know the room that I’m walking into, know the patient that I am there to attend to, know that it’s probably med admin time. So why can’t these systems, as soon as I identify, walk into the room, bring me the credential of the system through touch or through a more passive model, bring me right and present me the exact information on the patients I need, probably in the EMR that medication administration record, rather than have me move from room to room and go through the exact same exercise. And you can use that analogy, whether I’m a hospitalist, whether I’m a NA taking vitals, whether I am a consultant that’s there to do a specific consult on the patient. So, we really want to look at technologies that certainly facilitate access, facilitate the display of information and really look at how we bend the curve on clinician burnout and how we can support technologies and invest in research and technologies that really take that out. Those technologies are not mutually exclusive of security. They’re not mutually exclusive of other components that we have. They really are complementary. So, those are things in terms of direct research that we want that we’re looking to do and we want to do that will really kind of bend the curve in the right direction in terms of presentation, access and facility of use of these tools.

Paddy: Those are great examples. Let’s switch to the patient engagement on the patient experience aspects of what you just talked about. So there’s a huge innovation ecosystem out there that are really focusing on that one area. How to engage patients better, how to create better experiences. Big tech firms are involved in this, many health systems are developing their own applications. And of course, there’s a whole ecosystem of startups. There are getting billions and billions in VC money to develop these innovative new solutions. How are you going about transforming or reimagining, as you said, the patient experience are you doing it all internally? Are you using a partner ecosystem, a combination of the above? Can you talk a little bit about that?

David: Yeah, I think, you know, just as we see large organizations come together and I think, you know, whether its CVS-Aetna whether any large payers and different kinds of the retail model, I think we see an environment where we can comfortably exist as partners and competitors. So, the model of where we look at partnering into the delivery of some care, we compete in other areas. So, as we look at some of our own development on our patient’s experience and patient engagement tools, we are also looking at partnership with academic organizations, with regional incubators and hubs. We’ve recently acquired the Exxon campus across from one of our core hospitals, Fairfax Hospital, which is a 117-acre campus that we will be further developing and that will be one of our core innovation hubs. Within there we see academic partnerships. We see commercial partnerships. And we really want that innovation to be a regional hub where we develop these patient engagements, patient experience tools in partnership with the patient because patient first and really understanding and as we move ourselves through the care continuum, either as an in the arbitrary setting, as we hope not that much in the acute care setting, but we’ve got to connect to how the patient and family members feel and engage them in this development process. I see a lot of organizations doing wonderful work. Well, I question whether we really understand the consumer and we really understand the needs of that consumer and the fears and expectations of the different kinds of consumers we have. My dear mother in Ireland has a different expectation of care and different needs than my younger brother who’s more mobile-enabled that say than my dear old mother. So, I think we got to understand and engage the consumer as we develop these tools. So, I would hope that certainly, our journey will have a large patient, first patient informed component of how we developed these tools.

Paddy: Yeah. Now, talking about innovation, I wrote recently about the two-canoe problem for healthcare, which is you have it here and now that you have to take care of, keep the lights on. You also have to invest for the future. And as a system, as a sector, healthcare is still pretty much relying on fee-for-service reimbursement. Its only about a third of the payments are going through some kind of an alternate payment model or value-based care model. In this context now you know that reimbursement is declining. You have not as much discretionary funds as you need. At the same time, you know that to be ready for the future you make all these big investments. It was really encouraging to hear that you made this big investment in acquiring this large piece of land and you are going to build out innovation. How do you actually do the tradeoffs and how do you sort of build a business case for these investments at a system level? What kind of ROI expectations or non-ROI expectations? Do you have from these innovation programs? Can you talk a little bit about the thinking process on this?

David: Sure. And I think there are certainly a variety of different payment models out there in the different markets that I’ve been exposed to be New York, be it Merola Market, Pennsylvania or the Virginia market. I think successful organizations will always put patients first and quality first and outcomes, and I think everything else follows. So, I absolutely understand the two-canoe model, but I think organizations that focus certainly have to attend to that. But really, when our core focus is the delivery of high quality, high-value care, that I think the focus of the health system as we put our patients first, engage our team members and how we give the best value and the best quality outcomes possible. All the rest follows, I believe Paddy. I think driving one payment and you are chasing one payment model versus another I think is something we have to be aware of. But at the core of what we do have to be the delivery of world-class care.

Paddy: OK, let’s talk about the technology environment. Technology is obviously playing a very big part in the transformation that health systems are going through much more so than in years gone by. We are seeing a shift in the landscape. We’re seeing the big tech firms moving into healthcare. They’re offering their cloud platforms or other technology platforms, and they want to get into healthcare in a big way. But my firm’s research suggests that most health systems are really looking by default at the EHR system to drive innovation, to drive some of these patient experiences and optimize the investments. The big investments that have been made in the EHR systems before you go out and start looking at alternative or additional platforms. How do you see this balance between some of the capabilities of these big tech firms bring to the table Cloud, Advanced Analytics AI, machine learning, and so on with what EHR systems are really good at but may not be so good? How do you do the trade-offs?

David: I think I would challenge you something that there needs to be a tradeoff. I would go back to the comment I made about partner and competitor. Organizations like Amazon do a really good job of delivering hundreds of millions of parcels throughout the country and the world. We have much to learn from models like that in the health care delivery business. We are challenged as an industry with elements of patient care like Med reconciliation. We as the care community view acute care provider, be primary care, be you a pharmacy benefit management, be you a retail pharmacy. We as a system can do a better job of ensuring that we get the right medications at the right dose to the right person at the right time. And we minimize the harm that we, the health delivery system, the avoidable harm that’s out there. So I, for one, would be really keen to understand how we partner with organizations to learn from machine learning or learn from AI, or learn from analytics that we as an industry, we, the whole healthcare industry have not really looked at deeply to see how we can deliver better care to our patients and avoid some of the components that have risk and harm that exist in our system today.

Paddy: You make an interesting point about these partnerships and I just wanted to refer to some recent partnerships that have been announced, specifically the ones involves the health system, The Cleveland Clinic, and the American Well. You know that came out recently. We are seeing others too, Centene with Walgreens on the whole PBM space, Microsoft and Humana, Google and Mail. So, can you talk to what these partnerships really signify in terms of a market trend? And can you maybe talk about any partnerships that you’ve built similar to any of these?

David: Yeah, we certainly are, as we develop our Inova Center for Personalized Health, which is our new campus, we are creating partnerships with both academic and commercial organizations. I can’t speak to those at this point that will be coming soon, but I think it’s an inevitability. When we look at the opportunities that exist for us to drive more and more quality into care, I think it’s reasonable that we see large partnerships when we look at the national spend both here within our own country and globally, the cost of healthcare and the percent GDP that is invested in healthcare is not surprising that more and more large institutions and global organizations are looking at how they can participate and facilitate the delivery of better care. So frankly, I’m not surprised by this. I think I’m surprised that it took this long before us to start seeing these kind of relationships begin to evolve. I think it’s still in the nascent stage in terms of how we work together and how we align. But I think it’s there’s a level of inevitability to this and frankly a level of excitement. I think there are skill sets that these organizations bring to our industry that we have not explored fully. And they are far more mature in some of these other industries. So from my perspective, I see it as a catalyst to accelerate our ability to deliver quality care.

Paddy: That’s very well said. So let’s talk quickly about the non-traditional players that are getting into healthcare. You mentioned CVS, we are also seeing Walgreens get into the primary care, urgent care space, Walmart. Even Amazon, you we saw recently that Amazon made an acquisition of a company that does symptom triaging. They’re also forming partnerships to deliver telehealth. How do you see the landscape shifting in terms of the non-traditional players and where they fit into the future state of healthcare delivery relative to where traditional health systems are?

David: I think, again, there’s a level of inevitability when you look at these large players, these are some of the largest employers in the country and they are like all of our employers are seeing the cost of healthcare and the delivery of healthcare for their team members, for their employees continue to go up with the skill set that they bring. And I think there’s, you know, the capabilities that they could bring to such a large owned employee base and how they can have an impact on value and outcomes. Again, I think it’s exciting and I think it’s something that we should embrace. And like any significant shift in an industry, be it the steam engine, the motor car. I think those that embrace it and those that really want to understand how they can participate in the bending of the curve in the other direction, I think will be the ones that will benefit the most. I think organizations that don’t see the change and see where the puck is going may find themselves on the not realizing as much benefit as those that, you know, understand where the change is, embrace this change. And it is going to be a I think, a quantum change in how healthcare is delivered. But I think if we embrace it, we understand that we get comfortable with being a partner and a competitor. You know, this is one of the most exciting times to be in healthcare technology because of the new organizations that want to participate in the delivery of care.

Paddy: Alright let’s get to your final thoughts on a couple of things. I do something called a lightning round where I get to a top of my thoughts on a few emerging technologies and how you’re using them or deploying them in your own environment. So let’s start with one that you already alluded to a little earlier on artificial intelligence.

David: Yeah, I think again, when we look at how we still require our providers to manually enter data. When there are systems and tools out there in our homes that have facility to understand questions, to interpret questions, to predict questions for us not to be looking at technologies where we can leverage machine learning, leverage this kind of passive component of consuming and presenting clinical data, be it in a office visit, be it in a ICU, be it in a ward for that matter, the ability for us to leverage AI and machine learning to facilitate the delivery of care and move away from the keyboard. I envision a day in the future where 20 years from now a CIO will be talking to you and talking about, you know, the days when keyboards disappeared and you know, we chuckle. But it was not 15, 20 years ago where people assume surgical site infections were a inevitability of running in a ward. People thought that CLABSI an inevitability. And, you know, having an IV in somebody. Today, we’ve moved the needle in terms of quality and outcomes where they become more and more and never event. I’m looking forward to the days where we talk about Med reconciliation and harm that occurs around that process being a never event. I’m excited about the days where people chuckle and laugh about the times when we were acquiring clinicians to pack away at keyboards to enter data that system should and could be able to do for them.

Paddy: Yeah. So that UI-less interfaces or whatever they’re beginning to call them now. And that’s probably a perfect segue into the next thing I wanted to get your thoughts on. Voice recognition.

David: You know, I think the ability for us to understand voice in terms of the collection and assimilation of data and the ability for us to understand voice in terms of the IoT setting. When we look at attending and caring for people more and more in a home setting, tools and technology around understanding voice and understanding triggers of voice. I think it’s something that voice technology beyond just the ability to consume and present data. I think voice as a diagnostic, as an analytic tool in terms of care models would be interesting and exciting. When we look at safety, when we look at agitation, when we look at these triggers in there that help us identify scenarios or events where we could avoid conflict or avoid challenging de-escalate scenarios and predict scenarios. So I think voice has got a lot of potential beyond where we’re looking just now in terms of consumption and presentation. I think as I dare use the term diagnostic tool in our care delivery model. I think there are some companies out there doing exciting studies on voice levels and mood. So I think as we move forward, voice will become not just the recording, recording. I think it will become part of our diagnostic process.

Paddy: Yeah, that’s great. One more before we round this out. And healthcare, as I asked this, because healthcare is typically predominantly an on-prem environment. So cloud. Where do you see healthcare in terms of cloud enablement and cloud adoption in the coming years?

David: I’m a massive proponent of cloud technologies. One of the things that as we design and engineer and architect cloud solutions, it’s really critical that we understand the patient care and operations model of those clouds that we design. I mentioned earlier high reliability in our delivery of care requires high reliability and the availability of systems. So, when we in the IT world think about high reliability, we really need to shift and think about the delivery of care in our ambulatory acute care settings and how we design and architect cloud solutions that will support events that occur. I was privileged or lucky enough to be in Manhattan and supporting organizations during the 9/11 outrage. And these things, you know, unfortunately are something we have to think about a plan for as we design architect cloud solution and the ability across to ensure that the privilege we have of creating these tools and systems to support patient care and the architecture that we design around that support organizations at every potential scenario, what could occur. So I’m a massive advocate. I think there is a tremendous potential for value in cloud solutions. But we’ve got to be cognizant of how we develop highly reliable cloud solutions that will support highly reliable healthcare delivery.

Paddy: David, its been such a pleasure speaking with you and thank you so much for sharing your thoughts. And we wish you the very best in your new role and all success to you and look forward to staying in touch.

David: Paddy, thank you very much. Been a pleasure to talk to you today.

We hope you enjoyed this podcast subscribe to our podcast series at www.thebigunlock.com and write to us at info@thebigunlock.com

About our guest

Mr. Quirke joins Inova Health with more than 28 years of healthcare information technology experience, with particular emphasis on clinical transformation through technology adoption, IT strategy, IT operations, M&A transitions and IT outsourcing services.

Prior to joining Inova Health, Mr. Quirke was Senior Vice President and Chief Information Officer of UPMC Pinnacle, which encompasses 8 hospitals and more than 12,000 employees, and over 200 outpatient and ancillary facilities, and a comprehensive array of clinical specialty service lines. Mr. Quirke was also previously Chief Information Officer of Trivergent Health Alliance in Maryland, a managed services organization created by and supporting three health systems, Frederick Regional Health System, Meritus Medical Center and Western Maryland Health System. Mr. Quirke began his career working internationally installing and supporting electronic medical record systems globally, across Europe, the Middle East, and Australia. He subsequently spent 10 years with First Consulting Group working on large scale consulting and outsourcing engagements nationally at some of the larger U.S. academic medical centers in positions of increasing responsibility. He also served as Chief Information Officer of Frederick Regional Health System of Frederick, Maryland.

About the host

Paddy Padmanabhan is a widely published and quoted thought leader on digital transformation in healthcare. He is the author of The Big Unlock: Harnessing Data and Growing Digital Health Businesses in a Value-Based Care Era, and the CEO of Damo Consulting Inc, a digital transformation and growth advisory firm based in Chicago.

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The healthcare industry is going through an amazing change in business models

Episode #27

Podcast with John Glaser, Former CIO, Partners Healthcare

"The healthcare industry is going through an amazing change in business models"

paddy Hosted by Paddy Padmanabhan

In this episode, John Glaser discusses EHR systems at length, the burden on physicians from poor design and workflows, the opportunities to advance data interoperability in the near term, and the confusing landscape around information blocking legislation.

He discusses the “tyranny of a large number of good ideas,” which often leads to increased workloads for physicians and increases the overall costs for the health system with little or no business rationale for implementing many of those changes.

John notes that big tech firms are laying down the infrastructure to surround consumers with healthcare offerings based on online behavior and preferences, and predicts how technologies like voice recognition and AI will dramatically change our healthcare experience in the future.

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 today, John Glasser, Former CIO of Partners Healthcare, and now an Executive Adviser at the Cerner Corporation. John, thank you so much for joining us and welcome to the show.

John Glaser: Thanks, Paddy. It’s a pleasure to be here.

Paddy: Thank you. So, John, you’ve been a CIO at one of the leading health systems in the country. And now, you’ve been working with one of the big EHR providers. So, you must have a unique perspective on all the discussions that have gone on about the cost of EHR implementations, the burden on physicians, and of course, all the benefits of digitizing patient medical records. So, can you talk to us a little bit about how your views on EHRs have been shaped by your experience?

John Glaser: Yes, sure enough, Paddy. And I think, I mean, there are a couple of parts to the question you’re asking me. So, I’ll start with the one on the burden, which is one of the more pressing issues today. Clinicians concerned about the usability systems or when you look at it, you see a couple of things. You know, why there are some legitimate concerns that people are raising. Well, sometimes the design isn’t very good or could be made better. So, it’s not as intuitive it needs to be. There are too many clicks, it takes too long, etc. At times, as long as they are just bad designs, we can fix that. But there are also some ways, for example, using a lot of dimensions of voice recognition and the ability of AI to empower a voice and so other ways of interacting with the system. So anyway, one topic is ongoing work improving the design, using new technologies where possible. The second area that we could spend a lot more time or better ideas is changing the workflow. At times you see provider organizations and also their partners, and I see this at Cerner, where they just go live to turn it on, but they really didn’t go through a workflow changes or how best to distribute who does what in the clinic, et cetera. So, you can actually change a lot of work by moving the work around to better suited people to do this, that or the other. So that’s workflow can be improved a lot in some of these cases. The third of the times we ask the doctor to do stuff which is just kind of overwhelming. I mean, documentation can be onerous, and CMS has been recently working on just reducing the documentation burden. Also, you think when I was a partner, we always called the tyranny of large numbers of good ideas. Where we just say, the committee said, golly, we should have the docs ask about smoking. You know, that’s a great idea. We should ask them to ask about whether you’re safe at home. Yeah, it’s a great idea. One by each. All these are great idea, but you add them all up and they’re just crushing in terms of time. So part of it is sort of going through the record in finding out what do we really need the clinician to do here? And maybe sometimes we can use new techniques such as AI to sort of construct documentation that goes on here. And then the fourth thing is sometimes it just takes long. So, if I gave you, Paddy, a prescription pad to write me a prescription, how long would that take you? Three seconds, tops. I said, well, now I want you to sign on. Pick the patient, pick the dose, pick the drug, all that other stuff. Really good. How long would that take you? Well, 30 to 40 seconds. And so you’d take these tasks that happened all the time and you make them longer and there is probably no way to really make them shorter. We don’t know what that is. And the problem with that is the doctors. Well, what’s in it for me? Why am I spending all this extra? How do I gain here? We don’t have a very good answer for that. You know, we suck up time. They don’t really deliver much to you. So, the other part is you are moving the value-based care where you really do get rewarded for quality, so that you’ll say, all right, I’ll spend the extra time because I can see what’s in it for me. Anyway, there’s a multifaceted approach to dealing with the usability issue. Unfortunately, none of them are simple. It’s this progressive, you know, operating on lots of different fronts. So, I think that’s going to be part of it. I think there’s value here. I mean, and sometimes the value you can express numerically, you know, there’s fewer errors or there is turnaround times or things like that. But at times the value is really intangibles. If you have better communication with the care team. I’m sure if we do, around the world you measure communication in better decision making. At times you can measure and at times you can’t. But that’s true of IT in general. So, I think there is a, you know, what you see is we still have challenges and usability will always have this complicated, multifaceted value proposition. But nonetheless, I expect all of this is very foundational to say we really want to change the health care system, get into value-based care, engage consumers, etc. Can’t imagine that we can successfully do that based on a pile of paper.

Paddy: Yes. So, it is fair to say that it’s all a work in progress. And it’s just going to get better over time. But we know it’s going to hurt a little bit while we get there?

John Glaser: I think it’s fair Paddy. There’s no silver bullet here.

Paddy: Yes. So, one of the things that has been criticism against technology vendors as well as health systems, in all fairness, is the question of interoperability. Do you have experience in data interoperability challenges acutely as a CIO of Partners, but you also have seen it from the point of view of a major electronic health record provider. How long do you think it’s going to take before we get to a place which is similar to, well, let’s say, the banking sector is?

John Glaser: Well, I think a couple of things. One is, you recently did an article in Harvard Business Review on kind of what can we learn from banking and, you know, not only in banking but also travel. The travel industry is pretty well advanced in interoperability. Did you see a couple of things? One, in both industries the interoperability is partial. And the reason it’s not complete is two-fold. You know, sometimes there are no real reasons for the industry to cooperate. So, for example, in banking, as you know, and I know we can go anywhere and use our get access to our account or withdraw money through the ATM infrastructure shared by lots of different banks and financial institutions all over the world. On the other hand, Paddy, if you go into your account, and want to withdraw 20 bucks in the wealth part of it, you don’t have it. You only have 10. What it doesn’t do is say, I’m going to reach into your Bank of America account, see if I can find 10 bucks, transfer it and serve it up to you. That interoperability doesn’t exist. Why? Because the banks don’t want it to exist because they view it as a competitor problem. You know, you might reach it, and holy smokes! Paddy has got a lot of money here. Maybe I’m going to entice him to join my bank.

John Glaser: We’ve bank American join Wells Fargo. We know banks have no interest in that. So sometimes it’s incomplete because there’s no rationale business case for it to be present. The second is technology. Dances are always happening in interoperability of life. So, for example, you know, a lot of these are kids do this. They use these micropayments, where they sort of send a payment to their iPhone for 20 bucks for share of dinner together? Well, between MIT and others, there’s no interoperability here. Why? Because it’s too new in lots of ways. So anyway, the point is you look at other shoes and you see a partial, I think said, is it where? Yeah. But they’ve been successful. They’ve done some stuff. Sure. And how do you know what were the conditions that led them to that? Well, there are three things, one of which is they really zero in on particular transaction or try to connect everything to everything. They say, well, we’re gonna go after the A.T.M. sharing of the infrastructure or in our case in healthcare, we might say we’re going to go after authorizations and referrals. We’re going to try to connect everywhere, very targeted transactions. Second, those targeted transactions, there really is a business case. And sometimes in healthcare, we confuse use cases with business cases. Use cases – here’s how it works but doesn’t mean anybody will pay for it to work. But here’s how it would work. In business cases, there’s a real strategic, compelling revenue cost service rationale for this kind of stuff. So, they’re very good at that and getting agreement. The third is they have an industry body that pulls everything together. So, in swift or in banking, it’s a swift alliance. Ten thousand members. The banks get together and talk about how to settle at the end of the day. Debits and credits deposited against each other. They need to streamline that, so they know what your account is and what my account is the following morning. So, switching gears, in travel, the open travel lines exist to sort of help the travel guys. So, for example, if you go from here to there and you use two airlines in the process, your bags have to go from one airline to the other. Well, how did that happen? You know, it’s not only an interoperability thing, but it’s also a process. You know, what is the baggage person do when they take these bags off your United flight and move it on to an American Airlines flight? So anyway, they have these industry groups that bring everybody together, sort through priorities, business cases better. We may have that in the recognized coordinating entity that Oh, and to just suit up with a Sequoia project, et cetera. So, I think Paddy, what we’ve got to sort of take the playbook from those and to look at these three. And I guess the last comment I’ll make that just goes back to my days as CIO. You go into the board meeting. So, you know, we got 50 different requests for IT projects, grand total of One hundred million bucks. But we don’t have a hundred million bucks. We’re going to give you 30 million bucks. If you are all okay, Well, then of the 50, I can do 20. And so, we have to prioritize just because of bandwidth and because of money, et cetera. So invariably, a lot of the interoperability stuff never made the cut. You know, it never was a top contender with stuff you want to do for nursing or improve the revenues cycle or to improve security on the infrastructure. So, it wasn’t as if there were bad people making data blocking decisions. It’s just that the rationale was not as compelling as other rationales, et cetera. That may change as we do value-based care and there’s a greater reward for continuum. But it’s a classic example of a business case in a particular instance of a health system. The business case often just wasn’t strong enough to sort of rival effectively with other propositions.

Paddy: Yeah. So, you mentioned the CMS and the coordinating entity that they announced. Of course, the CMS and the whole industry, they are kind of into the middle of this. And they had this for the last couple of years. But there’s a lot of confusion, at least to me and maybe even to some of my listeners here. So, you know, we have the FHIR API standards of the CMS and ONC are working with HL7 organizations. Now it is the 21st Century Cures Act, there’s something called TEFCA that’s out there. How do my listeners unpack all these? Is it a simple way to unpack all these and understand what’s going on at a high level?

John Glaser: Oh, I think it’s a tough thing, Paddy. And you’re not like you mean you can read about Hollywood as the recognized court and what’s really behind tapped. But some of these is new. And so, you don’t really know how effective all of it is. And will it get tuned or altered along the way? And sometimes you go in and you say, golly, there’s this bill in front of Congress, that bill in front of Congress. And a lot of bills get put on it, put out there, but never make it anywhere and never give out a committee and never get voted out. And so, there’s a swirl of bills that come through. And even when a bill passes and it goes into committee and gets to an increase, their golly, it’s pretty fluid and the expert aren’t sure, etc. So, I think it’s really hard to do that. My best advice on that is one is if you’re with a large enough organization, a health system or a health plan or whatever. Usually, there’s a government relations person or a person whose job it is to be on top of what’s going on in government. Sometimes the IT stuff during the health system there probably also pay attention to Medicare rates or state level activity on Medicaid and other things like that. They’re paying attention to privacy laws that are so large. One of the things you do, you turn to say what seems to have such a person in my organization and I’m going to then talk to him or her periodically about kind of what’s going on. You know, on a regular basis, the best channel. So that’s one way to do it. The second way to do it is to, you know, you’ve got to go to conferences. I’m going to go to a Chime conference or HIMSS conference or whatever. And, you know, there’s usually a government discussion there, and I want to listen to that. The third way that people have is, sometimes they sort of have to subscribe to or have relations with lobbyists or firms in the D.C. area whose job it is to keep tabs on all this kind of stuff. So, you often see a health system with a connection to a set of folks in D.C. whose Job it is to monitor their rules and regulations that are going on, etc. And then you can finally join organizations such as the E-health Initiative or the Electronic Health Record Association. Many of them or D.C. based. You do preview a pretty darn good job of keeping on top of what’s going on here, etc. And then obviously you, Paddy, and I’m sure you do this from time to time. But I think it’s hard and there’s lots of other ways you can do it because there’s sort of this cottage industry that has emergencies as too hard for people to really keep on top of it. So, I will be a lobbyist in DC or an association or whatever it was design it is to make sure that you get the scoop on what’s happening and how it’s changing.

Paddy: Yeah, I read a recent report I think that was done by one of the big consulting firms, Accenture, which said that, look, this information blocking rules that the CMS proposed earlier in the year and was announced during HIMSS, actually. It’s coming. It’s coming down the pipe, may be down the road. Well, health systems need to get prepared for that, and their survey seems to indicate that people are not prepared, are not aware or don’t care or any combination of the above. So, John, just in light of your comments, is this even a big deal, should health systems be doing something in anticipation of all these things going into effect?

John Glaser: Well, I think it’s really hard for a health system to prepare for this because there’s this language in their Paddy and its fuzzy language. So, it says your health system has to make sure that patients can get their data with no additional effort. So, what does that mean? Or if you’re a vendor that you can’t you know, this can’t be _________costing or I mean, there are obviously costs that are way out of line. But we know what point you cross the line with your costings on this kind of stuff here. And that if, you know, someone says, hey, I want to have access to my data, you have to serve up everybody. Yeah, but I can get overwhelmed by this thing. Aren’t there ways I can part it? So, there’s a lot of fuzziness in the language about what do you really mean? I think the part of regulation is getting clarity over again. I spent a year ago and see where meaningful use is coming out and know the legislation said we’re going to give you money, you know, an incentive to adopt in the meaningful use of interoperable electronic health records. And that’s all it said. what is meaningful use me. Well, it took regulations to really say it means this. And we have all this very complicated set of certifications and this that the others come out of that. So, you take all these data blocking stuff and that specificity that we now see around these, doesn’t exist yet. And they’re still working on the rules to sort of create it. I think this could be really complicated. So, in a way your health practitioner says, I can’t prepare because I don’t know specifically what you mean. What do I tell my troops to do in the IT department or medical records department, etc.? So, I think all you can really do is do a couple of things.

John Glaser: One is to your point; you can pay attention and talk to your colleagues at consulting firms. What’s going on? The threat of the other. The other is to make sure that you are a part of and aware of what your lobbying or professional societies are doing, such as what is the American Hospital Association doing about this and they’re working out their hearts.

John Glaser: What is the AMA doing about this, the Medical group management association? Anyway, Organizations that represent providers are trying to work with Congress. We got to get clarity here and only clarity, the clarity that’s practical not just clarity that’s going to be awful. You know that we go through think you can do some basic stuff that goes through. But I think it’s really hard to get this until we get this clarity and all you can really do. And it’s worth doing this to work with, you know, organizations like the AHA to make sure that your opinions are known to them and that you’re hearing from them kind of where the conversations are in terms of creating the real rules and regulations that will give us all clarity.

Paddy: So, watch and wait, basically.

John Glaser: And but also stay connected to the organizations that are in D.C. trying to work with him and to get clarity.

Paddy: Yes. So switching topics here a little, so today the big buzz is all about digital health innovation, digital transformation, and you see a lot of announcements, almost on a daily basis, the big tech comes to the act in a big way, the Microsoft and the Googles of the World. We see a slew of partnerships that are being announced. You know Cleveland Clinic just announced one with Amwell. And the bunch of these partnerships are happening. And you have all these nontraditional players, a Walgreens, Wal-Mart and CBS. So, what do you make of all of this? Where is the industry headed at a very high level in terms of its competitiveness, in terms of a fundamental shift in primary care relationships and so on?

John Glaser: Well, it’s a fair question. And I think it’s remarkable time that this industry saw it. I think, you know, when you step back in Hollywood, the industry is going through this amazing change in business model, and business models basically says, I’m an organization. Here’s what I’m going to do. Here’s how I’m going to do it. And you are going to be like what I do and how I do it so much. You’re going to pay me and you’re going to pay me enough to make profit and maybe I’ll become rich and all that other stuff. Example is Uber, the business model is I’m going to get you from point A to point and say, well, yeah, that’s not all that walking does that fighting does that, etc. But who says, yeah, but how I do it is really different.

John Glaser: So that is for sure. And it’s pretty neat to all use Uber it better. So anyway, in healthcare we’re going from this shift of business model from volume to value-based care, from fragmented care to integrated care, from reactive secure you shop or fix you to proactive management of health. And from one which is really centered on the clinician to one that is more centered on the consumer or the patient. And as a profound business model ship, anytime you have a business model ship like that and it can be induced by the technology like the web or mobile device or by an arcade, a lot of payment mechanism people see opportunity. So, it’s not surprising that you see several tech giants and other organizations, retail, pharmacy, retail, that CBS is the Walgreens, Walmart, etc. saying, hey, we can do a whole bunch of these people stepping in. So, there’s business model shift, there’s opportunity when that happens. And I see how I can leverage some of my strengths to go off and to do this kind of stuff. So, I think we’re seeing this flood because of that going on. Now, what I think is happening is sort of the traditional boundaries between providers and health plans between the pharmacies and the providers are that these crucial boundaries are getting blurry. We are ________ whether it’s provider sponsored health plans that kind of are gone or Optum has a massive, you know, delivery arm, probably the largest delivery arm in the country, frankly. And, you know, as you see this, you know, in fact, I just got my flu shot at my local Walgreens this morning. And so, they’re increasingly getting into some basic types of care, let alone going on the Internet. And you can get prescriptions for E.D., drug or eye medicine, all kinds of stuff. What we’re seeing anybody records the stuff. Those are really fluid times. It’s going to go under. Now, how it will turn out, I’m not really sure. I mean, I see the tech giants, you know, the Microsoft, Google, AWS of the world. Well, they’re really doing sort of two things here, one of which is providing infrastructure. And so, Apple, for example, with healthcare and research kit, is providing infrastructure for you to develop new and cool stuff, whether you’re Cerner or an Epic or whether you’re a health system or whatever. And they benefit because they sell more iPhones and watches and stuff like that. So, they’re all doing infrastructure. Sometimes it’s cloud, sometimes it’s Apple creating healthcare set up. And now, the infrastructure of case of hosting, but also tooling, which is AI tool or voice recognition tools, you know, Siri things along those lines or so. Anyway, the tech giants are saying I’m going to deliver infrastructure so that as you guys go through, this is a model change. You can do all kinds of pretty cool stuff that’s going to go on. The other part is if you look at particularly Google and Amazon in particular, say increasingly they want to surround you and I as consumers with all facets of our lives. So, on Amazon, if you order something, Paddy, I want you to order ninety-five, maybe 100 percent of everything you ever buy through Amazon. And it’s not only books and electronics and this and the other, but now it’s groceries. And increasingly, you’ll be durable medical equipment, your health care stuff. So, I just want to surround you and make it really easy for you to order everything. Now, there’s a lot of value for me in that I want to sell advertising I can so, you know, I can charge money for a little bit of extra kicker for all these proposals that are putting. And also, I get to know you. So, you’ll see the sort of personalization coming in here and calling people like you bought X. So, I’m going to use all that knowledge and all fancy and sophisticated intelligence and great supply chain, et cetera, to surround you and be much more effective at making money off your daily activity. Google, on the other hand, which is also trying to surround you. You’re trying to surround you based on searches that you do. So, is Paddy interested in looking at locations, is he looking at what it’s got a chronic disease, what does he look at? And I want to surround you. And not only do this search improve Dr. Google, for example, but also in your home, you know, we know a lot more about you in your home or to make it ___________ So I think above and beyond the infrastructure, in particular the case of Google, Amazon they surround you in an ecosystem which we actually benefit from and use a lot, which they increasingly understand us and health care becomes a critical adjunct to understanding hobbies and understanding financial status and understanding, you know, whether you have a big family or a little family and all this kind of stuff, anyway, they’re getting into health care just to round out their understanding of you and surround you with support based on things you buy or questions that you ask. So, what all this mean to the, you know, the Corners and Epics and _________ all those folks? I really don’t know. You know, you see the Cerner AWS announcement. I suspect increasingly there will be this effort to put another layer on top of the EHR. a layer that’s kind of like the population health, but, you know, essentially, it’s a platform that sits on top, pulls in data from devices and pulls the data from claims, engines and charts and provides a series of additional services to you and me as individuals, and the health systems and also the life sciences. So anyway, that is going to a remarkable time to see how this battle settles out.

Paddy: Yeah. And this is obviously the whole competitive landscape is shifting. So EHR vendor is kind of moving upstream and they’re getting into more of the value-added world. And of course, the big tech firms are trying to move into more of, I don’t think they’ll ever become EHR vendors. I could be wrong. So, they need, the emerging needs are all about analytics and user experience and so on and so forth. Now, one thing that I hear a lot is that the health care, the relationship between the health care consumer and her primary care physician is a unique one, which is built on trust. And, you know, no matter what you may say about the brand value that Amazon e-commerce platform or a Walmart or Walgreens, there are certain things for which, you know, the trusted relationship between the physician and the patient that’s kind of unbreakable in some ways. Now, there are generational differences. Millennials have a whole different approach. They don’t even have a PCP in the first place. And, you know, the boomers, on the other hand, are used to a certain way of consuming health care. Does a shift in demographics play a role? Is it going to play a role in how healthcare is going to be served and consumed in future?

John Glaser: Well, yes and no. I think a couple of things. One is you and I and everybody don’t care whether you’re 22 or 82. You have two different types of relationships with the health care system. One is what I call truly transactional, like today. I want to get a flu shot. You know, I could I did it. A Walgreens is nearby. But it didn’t matter to me whether it’s CVS, you know, and, you know, the nice lady who gave me the flu shot. I mean, I don’t know who she is. I don’t really care if I renew who she is. It’s better if it’s a transaction. It’s like buying groceries. You know, we want that. We want good grocery. You want to pay the amount. But, you know, I don’t really care whether the person is checking me out and I ever have a personal relation. To that aspect of health care, we’re just transactional, pure and simple. And again, you could be twenty-two and it’s transactional. You can be 80 to it is transaction. So, there I think, you know, the retail guys will do just fine because at the end of day, we want good, convenient, high quality, relatively inexpensive service. There’s another category relationship, called agency, which is why it is different. You know, my relation to you is based on trust, based on the fact that you have knowledge that I don’t that you have experience that I don’t, and I never will. Frankly, I trust you will be smart and thoughtful, care about me, et cetera. Know an agency relationship can exist with your doctor and if you have cancer or, you know, weird or scary and neurological disease. I don’t know you. I trust you as an agency. It also exists with a financial planner. Most of us, you know all these options ________ Paddy, maybe you’re all over this stuff. You Know, I trust the financial planners. Listen, John, you want to retire. You want to send a kid to college. Here’s what we got to do here. And if I had a complicated legal situation, I would trust an attorney. I don’t know. You help me. So anyway, the point is we have agency relations to several different types of people, including our doctors, etc. that we will always have. Now, it’s interesting, me, Paddy, I have three daughters. Thirty-six, thirty-three and thirty. And the 33-year-old and a 30-year-old are new moms. You know, within the last year, both had grandkids. That’s how I view them. So, it’s very clear to me that those my daughters value enormously the personal relationship with the pediatrician and value when they were pregnant. The personal relationship with their obstetrician. Now they’re millennials. But, you know, they want a healthy kid and they want a pregnancy without complications in the sight of the other. So, they might be millennials and they’ll willing to do certain they’re more comfortable with the technology than I am. But when it came to stuff that really mattered to them and when it came to stuff where they said, golly, you know, the stakes are high and there’s an imbalance of knowledge here, I trust and need that data. So anyway, I look at that and say why on one hand, millennials will try to do more of this. But on the other hand, all of us have, you know, retail transactions and health care in my daughters, as young as they are, you still have the value trust relationship as parents.

Paddy: And I think that’s very well put actually it’s pretty nuanced. So just to round out our discussion today, John, you talked about a bunch of the emerging technology. You talked about voice enablement. And I think that this fantastic scope for increasing productivity and reducing the burden on physicians just to voice enablement. And I think there’s already progress being made in that. You talked about cloud, how Cerner in particular is driving relationships with AWS and all the other cloud lenders are getting it. I just want to talk with quickly about AI, what you think of AI’s potential.

John Glaser: Oh, I think, Paddy, I think it’s massive. And I think, you know, it’s interesting, if you go back over the history of business use of IT, every decade, there’s a class of technology IT technology would just change the world. The world’s different as a result. So, in the 60s, it was the mainframe computer. In the 70s, it was the minicomputer. In fact, you know, the Cerner – Epic ________ they were all born of the mini computer. In the 80s, it was a network personal computer. When I came on the scene, I saw it.

John Glaser: And you could really do your own computing power, connect the printer stuff and use Ethernet, all that stuff. In the 90s, it was the web that debuted. So, you know, Amazon founded 1990 for Google in 1998. The world’s a different place because of the Web. In the 2000s, there was the mobile device and, you know, high speed wireless network. You know, the iPhone debuted 2006. So, and also and you look in a very short period of time, 15 years, how much the world is changed because of the mobile device. Is it in the current decade? What does it say? You know, the world will change because of that. Now, sometimes these changes play out over a long period of time, decades. For example, in this country, we are all sort of concerned about the web being used to influence elections will shoot. You know, this is 20 years into this revolution. Now we’re still learning about both the pros and the cons of the technology. Anyway, AI will play for a long period of time. I do ________ or are sort of focused on calling what we remove the need for doctors and, you know, and wheel cars really be driverless in all circumstances. And we get, you know, a little too ahead of ourselves. But it’s here now. Least, you know, Siri, for example, Alexa has remarkable A.I. capabilities. My wife has a Volvo XE night and you couldn’t crash that car if you wanted to. You know, the A.I. that keeps you from drifting in the lane and getting too close and parking and all those kinds of other stuff. So, there’s A.I. everywhere across us. And, you know, I see the same in the machine. You know, the logic will look at machine say the performance of part sixty-two is getting a little erratic here. I think it’s going to fail in four hours. So, let’s I’m going to dispatch a message to a technician to get out here with a new part Sixty two before it goes down. Paddy, we will see profound change. It’ll be multifaceted. It’ll be all over the place. It’s not like it’ll be here or not there, et cetera, in our professional lives, our personal lives, et cetera. You will take decades to play out. But nonetheless, you and I will have this conversation 20 years from now and we’ll say, golly, look at the change that A.I. It’s happened. And I guess part of the cool thing is, if that’s really true, that every decade is something changed the world. What’s next? That’s good question. It’s usually hard to see the decade that is going to come, but it invariably comes.

Paddy: Well, John, it’s been such a pleasure speaking with you. Thank you so much for sharing your thoughts. And thank you for being on the show.

John Glaser: My pleasure, Paddy. Thanks for inviting me.

We hope you enjoyed this podcast subscribe to our podcast series at www.thebigunlock.com and write to us at info@thebigunlock.com

About our guest

As an Executive Advisor, John Glaser Ph.D. is focused on advancing Cerner’s strategies and thought leadership position in the industry.

John joined Cerner in 2015 as a part of the Siemens Health Services acquisition, where he was Chief Executive Officer. Prior to Siemens, John was Vice President and Chief Information Officer at Partners HealthCare. He also previously served as Vice President of information systems at Brigham and Women’s Hospital.

John was the founding chair of the College of Healthcare Information Management Executives (CHIME) and the Past-President of the Healthcare Information and Management Systems Society (HIMSS). He is a Former Senior Advisor to the Office of the National Coordinator for Health Information Technology (ONC). He is the former Chair of the Global Agenda Council on Digital Health, World Economic Forum.

John is currently a member of the boards of InTouch Health, the American Telemedicine Association, the eHealth Initiative, PatientPing and the National Committee for Quality Assurance (NCQA).

About the host

Paddy Padmanabhan is a widely published and quoted thought leader on digital transformation in healthcare. He is the author of The Big Unlock: Harnessing Data and Growing Digital Health Businesses in a Value-Based Care Era, and the CEO of Damo Consulting Inc, a digital transformation and growth advisory firm based in Chicago.

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Sign up to get Paddy’s Newsletter that is personally curated by Paddy along with analytical notes on the developments for the week.

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Sign up to get Paddy’s Newsletter that is personally curated by Paddy along with analytical notes on the developments for the week.