"We want to define what ‘good’ looks like and prioritize our digital health investments accordingly.."

Q: Tell us a little about Sentara, what populations you serve, and your background. You’re relatively new to the provider space, but not to healthcare. How did you get into this role?

Timothy: Sentara’s been around for over 130 years as a nonprofit mission delivering care to the community. Over 20-25 years ago, it started supporting health plan and insurance products across multiple lines of businesses.

Sentara’s made up of 12 hospitals that cover almost a million health plan lives across Medicaid, Medicare, the individual, large, and small groups. The bulk of that — 60% plus — are in the Medicaid space and from a regional standpoint, across Virginia. It was originally founded in the Hampton Roads area, but now caters to Northeastern and North Carolina, as well. We have a College of Health Sciences, nine Magnet Nursing Hospitals, over 300 sites of care, more than 900 physicians, over 470 advanced practice providers and 1,370 medical providers. So, we are a large organization both, on the care delivery and the health plan insurance sides.

This year, for the first time, we’ll be about 50-50 in terms of overall revenues between the health system and the health plan. That balance, as we continue to grow both aspects, really allows us to do some interesting things — in terms of providing access and proper care — as an integrated delivery network that’s also linked to a large membership health plan, especially for an underserved population like Medicaid. That’s important and particularly, meaningful to me because I started my career on the payer side about 25 years ago when I first jumped from finance into the health care world.

On the health plan side, initially, I worked in the Medicaid fee-for-service domain. That was my first experience with health care and delivering services to a needy population country wide. That imparted a different level to the mission of what you needed to do to provide these services that they so critically relied on. Through that process, I progressed through several different large payers and other lines of business where I involved myself with all types of membership – uncommercial, commercial, and the government-side. Recently, I left Anthem Blue Cross Blue Shield and came over to Sentara, the provider nonprofit side of the world.

It’s been a great journey and I’ve got involved with an even more mission-driven organization that is doing, and not just helping, from a health insurance standpoint. Engagement in direct care has also been really rewarding. It’s interesting to learn that process and be part of this organization.

Q: You bring a unique perspective to your role as the CIO. Can you share some of the unique needs of an entity like Sentara? Many would refer to it as a payvider network, a payer and a provider). And from your perspective, how do these drive your technology priorities as a CIO?

Timothy: I experienced this concept — of trying to create value-based contracting and care and building incentives to drive that collaboration where there’s the same incentive for the insurer and the care deliverer to provide the best outcome and the most affordable, accessible care for the end consumer — on the payer side. It shouldn’t be different — a different incentive or a different goal — just because I’m a payer versus I’m a provider.

What we found was that — when we were just in the payer space and trying to get providers to focus on that value-based care and sign-up to some level of risk, which health insurance companies have been doing all their life – it was a very difficult and new concept to grab hold of, as a physician and a care provider on the other side.

There’s a trust-based partnership that must work towards getting the best outcomes. You’re not trying to win on either side, but provide what is the best, most affordable, accessible services that benefit both sides of that equation. Even though I was part of a large payer, trying to get providers to be engaged or forced into that was difficult because trust levels weren’t too high. I thought, “OK, I’ll come here, and we’ll own our providers and the health plan. It’s natural that they’re doing this value-based and trust and that’s happening.”

But there are a couple of different things, such as, being fair, adhering to compliance and regulatory norms that prevent some of that interaction from achieving the depths, they could otherwise have. A lot of it is, once again, their incentive, in their own kind of tower around certain goals to deliver for the organization, as opposed to bringing this in and looking at the overall goal and how that coordination can work better in our microcosm.

Theoretically, I’m supporting all the technology, data, and analytics needs across sides, so, I should have that visibility and unite that. That’s part of the goal and how we measure success, here. To see that come together better and then, take that beyond to say, “How do our hospitals and providers also interact in that value-based way with payers that we don’t own?” We’re not part of these other broader systems’ drive because in our regions, there are plenty of other payers that have many more members. We serve for our care delivery than our own health plans, so, we want to be able to do that, take those lessons and scale those across our entire ecosystem of external payers, as well.

Q: From a technology standpoint, data is in common use of some of these platforms. Can you touch on one or two opportunity areas in this regard, as you look at it holistically?

Timothy: It’s about building a foundation and continuously adding layers to that to allow easier interaction and connectivity. Data has got to be that foundation, so it must flow ubiquitously under the right security and usage rights so that it can be shared to get the best outcome for the care. It must also enable understanding of where the care gaps and other activities lie. We can be proactive to both benefit and create a lower cost of care, while also providing the right services at the right side of service, irrespective of location — in a hospital or at home – to make that outcome the most affordable and the right best outcome for overall health. So, clean, linked, uniquely identified data is critical to that for it helps us know that the consumer and patient entity is the right one.

Once we have the right data set, we roll it up for insights into how we’re performing from a population health standpoint, a practice and cost of care, and the insurance side right down to the way we’re delivering care to that population. What can we do to improve that and be more proactive on some of the care that helps prevent a higher cost of care down the road?

That is interesting and challenging because from a payer standpoint, you have a membership for one year, when you’re enrolled in the plan. You can leave the next year, but you don’t get the benefits, then. But if you think about the solicitor, you care about the health for the next 50-60 years of that population. You have to look at that more holistically.

On top of that data, then, I think about an engagement or a visualization layer that has to be digitized. How do you ensure digital engagement for members and patients to ensure they’re engaged in the best outcome for their own health and take some responsibility for that engagement? We also have our care deliverers, care managers, disease management managers, caseworkers, home health workers etc. so, how do they have that digital interaction with and visibility into that data to also optimize that care overall?

And then, there are pieces that go beyond just the technology to deal with how you get those operational workflows to work. These did create some great dashboards of data that theoretically could lead the providers to the right areas to do the work. But it was a standalone dashboard that was created, and it wasn’t embedded in the workflow of the EMR. So, whatever be the workflow EMR, it’s important to think of how we can transact and deliver care. We’ve got to move to that next level, above the data, go digital to figure out how to embed that in the workflow to promote engagement.

It’s not them having to get out of their normal workflow and look at other things. Part of that workflow, besides engaging their EMR, is also doing other things that allow them to engage more of their time more effectively, so, we can start getting into Natural Language Processing, natural language understanding, Machine Learning, AI, voice, etc., things that can help with the fatigue and burnout yet get the documentation that’s needed, out. We need good programs across the board to measure this from a payer and provider standpoint.

Q: You came from a large health plan, and in general, they’ve been slightly ahead in their use of technology and data-enabled strategies. Tell us about your initial impressions as you came into this organization and do share your priority areas, as you try to bring these two organizations together to drive synergies.

Timothy: There are a couple of things. I came into this with a viewpoint of “How do we build up the conferencing capability of our technology platform or infrastructure?”

First off, I wondered “How simplified is our environment? Can we simplify further?” We were in a good place from a simplification standpoint. But were equally good from a security standpoint? Did we have a good security posture? These are all like Maslow’s — you’re going up the spectrum of what things you have to have in terms of food and shelter. This is the same thing. Then, I thought of resiliency. “Do we have a level of resiliency for disaster recovery and business continuity?” We didn’t have that, but we were trying to do the most advanced digital care, remote patient monitoring activities. This was going to be difficult and problematic without a robust foundation.

I looked at that and then, at scale because if that’s absent, then, growth, affordability to do this on a broader impact is tough. You have to change what you’re trying to tackle your goal. If you don’t have a platform that can scale and support that growth, that’s another missing foundational piece.

Those are areas attacked early-on in the process. Fortunately, the previous CIO had done a great job for the previous three or four years. They’d undertaken Cloud transformation and as a foundational infrastructure, got 80% of our platform stack — on the health plan and the health system — into a single Cloud structure and a segmented, secure environment for that data and that compute. What this enabled us to do was scale because cloud translates to your agility to be able to scale-out, scale-down and be secure within that compute environment. So, security was another piece of that.

I also undertook additional security adversary simulations to see how good we were both, physically and digitally. I checked our disaster recovery to change our recovery time on our core Tier one systems from what was almost 20 days with tape and off-site recovery to an actual real time instance between Cloud to Cloud that we could replicate and get our DVR system up in four minutes. That was a massive change.

What we’re putting on top of that now, are expanded data layers where we’re engaging more with external and broader types of data, including partnerships with companies that have Deep Learning and products in AI and Machine Learning and use NLP. We’re engaging in a digital transformation that takes us beyond just a portal to really something that can be a framework for all types of digital interactions and provide broader virtual care platforms.

If COVID showed us anything else, it was momentum around what we can do from anywhere in terms of meeting patients where they need to be and providing that care in a more virtual world. So now our platform can scan across the entire way from hospital all the way down to home and spans wearables from an on-the-move standpoint, that enable interaction. That kind of platform means we’re really stepping up.

When you think about all this capability and connectivity, you’ve also got to step-up on how you think about CRM or customer service support. When you think about a contact center in environments, it’s not just about calling a phone and being told “I’ll call you back with an answer.” Interactions now have to happen through all sorts of omni-channel connections, we need folk that are engaging at a higher level of competency and knowledge to really provide true omni-channel interaction experience where people feel like they know them. It’s personalized and encourages engagement because we need that engagement every day across our system.

If you think about it from a provider standpoint, we average more about 2.7 interactions a year with our patients. This isn’t enough to get engagement, trust, or even the full breadth of health and wellness that we have to bring to that population. We want to increase the interactions and it doesn’t have to be every day because I think they don’t want to interact with us more than 2.7 but because they’re interacting with us from a sick care experience. We want to think about health and wellness in their interactions, whether they’re doing really well or they’re doing really poorly. They’re interacting — not necessarily paying anything — because we are now their trusted ecosystem where they want to manage their health and wellbeing and that of their family and extended family.

Q: You referred to Cloud and CRM. Can you tell us where you are in your Cloud transformation, migration and CRM journeys? In that context, where does your core transaction platform for the health system, Epic, fit in?

Timothy: Great question! We’ve focused on getting those Tier-one platforms and EMR such as, Epic, on the provider side, along with the core claims processing, financial billing, payment systems on claims systems to support the health plan side. We’ve migrated both into Microsoft’s Azure Cloud. We have multiple segmented instances where we control who accesses what systems across that.

We also have regional instance as a direct primary to support that and so, the bulk of our compute, as well as all of the data and reporting, is up in that cloud. We spent time on this and have a provisional patent that’s tied to what we did with our cloud transformation. That patented solution will be leveraged with our lessons learned over the past three or four years, which are more than just how to get something in the cloud, such as, how do you change from CAPEX to OPEX? How do you convince the board in ELT about the value of cloud beyond just saving dollars?

It’s about agility, how fast you can move, spin-up and spin-down, how easily you can interact with other cloud-based systems and technologies like Salesforce and CRM. That’s one of the tools we rolled out — Workday on April 1.

These are all Cloud-based systems that can interact better in a Cloud environment. One of the things we pushed hard over the past months, and which will emerge soon, is a spin-off, a for-profit Cloud IT services organization built-up in terms of capability. The aim was to get talent to keep growing and do what they want to do in a for-profit world within a new company, a joint venture, where those folk can grow while we retain and get the best technology folk that will work for an environment like that without thinking of their primary IT job being working for a not-for-profit health system.

That’s a tremendous story in terms of what we did, how we learned how to do that effectively, and how we ate our own dogfood. Now, we have a framework in a construct that is licensable and driven towards a pattern that is real IP. Thus, we can help other health systems or payviders on their foundational journeys to the cloud while helping them realize the benefits of all these other areas and components.

I’ll briefly also answer the CRM component. There are number of CRMs today and the most recent one that we rolled out leveraged Salesforce inside our health plan. But I would like to think of it more as a CRM or a contact ecosystem of all those omni-channels – something that’s more than just your standard, old school CRM. Even if people don’t think Salesforce is old school, the old school deployment of a CRM or a call center is very different than where it needs to be in terms of a true contact center or contact ecosystem.

Q: I see some other progressive health systems doing the same thing – Providence and Intermountain come to mind — Is it just being opportunistic? What is driving it – talent?

Timothy: Great question! It’s really a mind-shift from coming from a for-profit payer world and what we would have been driving towards, which was generally around profit, spending, valuations, and spinning-out overall dollar values.

First, it’s a belief in doing this and being really focused on a couple of different problems. It’s reflecting to our community and the outside world that, “Hey! We are progressive, we’re innovators.” We’re trying to drive for those best solutions — not just clinical solutions — that can really fuel the best outcome for our communities, patients, residents that we cover. So, part of it is about being progressive, innovative and showing our commitment to that as a 130-year-old Sentara.

Second, it’s around our talent and commitment to members of our team, who are the most important aspect of our company. They’re the fuel and everything to what we deliver to our customers as value. Being able to create an environment where I don’t have to outsource to lots of different technology-only vendors, all my expertise and my jobs for my region, enables those folks to develop, grow that technology world and not feel like they have to go to a Google, eBay or Microsoft. That helps them connect closely with the mission of making our environment better.

We care about other health systems — Intermountain or Geisinger etc. – and we want to be a part of that. That’s an important piece of the value. It allows us to take other technology compensation capabilities and have a place for them to land so as to retain, attract, be able to get that talent into that environment.

Since you mentioned Providence and Intermountain, we’ve worked with the former and that was the first system I was introduced to when I first started here a year and a half ago. One of the companies that was spun-out of Providence right through that — an AI, machine learning, digital data company that’s for-profit — as part of that Series A and with another 20 other health systems with the same mission. That’s a great story.

Intermountain was involved in Graphite — a not-for-profit as opposed to a for-profit. But the previous year I spent time with Ryan who’s just announced he’s moving over as the CEO for Graphite Health. It’s really an environment to allow all the talent to help build more competency and capability on our own whereas probably historically, we were held hostage to all the technology and vendors out there that were doing these things to us. Now we’re becoming more mature and our ability to do some of that for ourselves is critical change in the mindset of historically a not-for-profit health system.

Q: Now you have an EHR vendor, Epic, and the opportunity to work with enterprise class technology companies, Microsoft, ServiceNow, Salesforce etc. There’s also this growing ecosystem of digital health startups that are bringing a lot of innovation to the table. How do you parse through this landscape as a CIO, managing the risks yet driving innovation as you transform your organization?

Timothy: Another great question. It’s a tough thing to solve, no matter where you are, how big you are, for-profit, or not-for-profit. Knowing every startup, every technology and where it’s progressing, what’s real and what’s not makes for a very confusing, chaotic environment out there. That’s a difficult thing to attack.

What it leads to is what I inherited when I first came in here, and started looking at our digital transformation program, enterprise wide. I inventoried almost 150 different digital pilots or proof of concepts going on all over the place with IT’s involvement. Now, you want some of this innovation to happen, but you don’t want to happen in chaos. In that way, where you have six solutions for the same problem, there emerge duplications, so, I brought in a digital officer and started making an inventory. Then, we collapsed that back down so as to clean up and evaluate the environment before adding more things to the pile.

I would also recommend having some good, trusted partners to help you in that journey of assessment because they can focus greatly on that marketplace while you focus on your full-time day job. After inventory and collapsing, you need to get control over what’s happening, herd the cats and ensure governance in that model to figure out what you’re trying to solve and the solutions for it. I found that we were bringing in lots of solutions looking for a problem, but we weren’t doing well. It’s important to define what the problem is, what good looks like, what the outcome that we want to achieve is and what the value, if we were to achieve that, is, and then prioritize those things that bring the highest value. Then, go, attack in a structured way.

The best solutions — either things you already have in-house or integrate or new solutions externally that you bring in to help solve that problem — enable a constructive way forward that isn’t about “Here’s a great cool technology, let’s figure out where we can use this.” It’s about understanding our big problems and our big value creation across the system, and focusing on those two things. The beauty of that is, once I have that construct now, I stay focused on what I really need to solve. When I get 20 emails a day from various vendors and both, internally and externally, I can put it against that lens and say, “Hey, that doesn’t fit in my top priority things that I’m worried about. I’m not getting 120 for another 18 months. So, come back and talk to me then.”

Q: As you go through the rationalization process, are you leaning more towards an EHR-first approach towards your digital engagement solutions and opportunities, OR are you looking at each individual opportunity on its merit and evaluating all the best-in-class solutions out there, regardless of whether they come from your EHR or not?

Timothy: It’s a good question. Before I joined the health system, they created the Sentara app focused around Epic, and the approach taken was to leverage Epic’s API. So, we integrated our own solutions with the API framework, to create a very customized environment.

What happens with Epic is, they’re investing a ton into moving certain things forward, especially in MyChart and that environment continues to improve. When you’re always a couple of releases behind the API, they aren’t keeping up with the capabilities. So, Epic’s ability is not to do a generic MyChart, but the MyChart extended framework allows us to operate — I don’t love the term Digital Front Door, but — a digital environment that not only supports but enables seamless interaction with its capabilities and functionality. It also allows me to bring in other types of solutions and connect other product sets within that framework.

So, we are moving more and more to that framework to create a cohesive application or digital environment that includes the help. So, if I’m a patient and an optimum health plan member, I want that digital engagement to be seamless in terms of me seeing my care, what I need from each exploration of benefits, what I need to pay from a building standpoint, my premiums, and everything for all of my family across all those spectrums. It’s not just about “Can I be Epic-first?” only. There’s no way because I have to cover all those other solutions as well.

That being said, though, what I need to go out and figure is if I’m going to use a solution, I need a certain solution — a certain hammer for a certain nail. So, I go to my key partner and core vendor like Apple and say, “Hey, listen, this is what I need. Do you have it or will you have it soon?” Or, “It may not be the best solution in the marketplace but is it the second or third best? Is it 80% or 90% of what I need and good enough?”

If it is, then, I’m going to leverage that framework because I need that discipline around creating a simplified environment. I’m not letting my environment go back to a bunch of cats running everywhere. So, the framework keeps it disciplined and herded. If the answer is not always going to be Apple, it needs to be our first place to validate that across.

Then, a second place would be the rest of our solution portfolio right in our CMDB to see the assets in there. If it’s not, then, we need to tap the right solution and define what we’re looking for and how to score for those solutions in a fact-based way that allows us to make the right decision, not because somebody has a brother-in-law or their next-door neighbor or they know somebody who knows somebody, which tends to happen. At least, that’s what I’ve observed can happen in these environments.

Q: Can you talk to us about how you’re managing the governance for all of your digital initiatives? What’s your org. structure? How do you go about making the investment? Is there a pool of funds that you know that’s signed-off of the border?

Timothy: That’s probably a full hour topic on that front! I spent a lot of time on that early in the process, because governance, especially across our digital properties, was a little all over the map and there wasn’t good correlation between the financial investments and the results and whether those results were achieved without financial investment and how that investment got added, was ad hoc.

So, we came up with a good idea. I spent a lot of time besides inventorying and consolidated rationalizing to figure out what the right governance teams were and finding the right senior leaders that should be part of what we call the G9 — the top nine leaders that are engaged in approving both, funds and prioritization. It’s an interactive model where they’re engaged. They’re the Steering Committees you find historically which are here, but the people on it aren’t showing up to the meeting. They weren’t engaged and they didn’t know that they needed to be actually rolling-up their sleeves and being embedded in this. They actually got to put in that energy and engage in it. If they did not engage, they’d be replaced with another who wanted to engage irrespective of seniority.

It wasn’t enough to engage, they also had to be empowered to make decisions. If we needed to make a decision on something, we didn’t need to go to somebody outside of the G9 to ask, “Mother, may I?” That was a top governance piece.

Below that, my Chief Digital Officer created a Chief Digital Steering or Execution Team that comprised people from IT, the digital team, and every operational area that’s out there. Part of this also was about going to the senior leaders on the G9 and saying, “Hey! Listen, I need a strategic person, an operational person that knows your business in and out. They have to be empowered to be able to engage anywhere and help shape the things that have to be done in that area, whether it’s around their strategies or where they’re heading, or whether it’s operational re-engineering that needs to occur.” So, we created that broader core team that is doing that day-to-day work.

We executed on creating that prioritized portfolio. Now, we have sponsored an Initiative Owner for every initiative in that digital portfolio, which we didn’t have before. There were no sponsors that were engaged or held accountable for being engaged. So now, we have initiative. Now we say, “This is a great idea. If you want the initiative, you must also have a sponsor. Do you have one? Do you have an owner? Here’s the definition of an Initiative Owner. If you don’t have one, we’re not going to approve that.”

So, it’s not just about saying this is the right list; it’s also about checking if we have the right skin in the game to make it successful because you can’t do digital transformation off the side of your desk. It’s a core component that’s all encompassing of people’s time.

Q: How do you see the role of the C.I.O. today and what has changed in the last couple of years?

Timothy: Great question! There needs to be a certain amount of technology background and engineering discipline involved because this is a complex world where technology gets bigger and bigger in the forefront of enabling business and a lever in the business.

Historically, where the technology and technology leaders were thought to perhaps be the necessary evil to keeping the lights on, things running, and my computer working, it must be a strategic lever to our overall enterprise, special business and operations strategy.

In some of my roles, I’ve always been an engineer and a technologist by heart, driving architecture environments both, as C.T.O. and C.I.O. In my last role, I held Chief (Operations) and I.C.O. responsibilities in Governance. So, understanding the business and the full value chain from beginning to end is a critical part to being successful as a technologist and especially, a critical part to be a successful C.I.O.

If Sentara wanted me to join as a C.I.O. to just run technology thinking that I’m a technology guy, I probably wouldn’t have come here. I would only want to come here if they saw me as an equal business partner at the table, figuring out what we want to do with this growth strategy, what lines of business we want to grow, the additional care services we want to expand, the M&A work we want to do etc. If I don’t have an equal play and an equal seat at the table and if I can’t say, “This matters and I have an opinion on things more than just technology,” I wouldn’t have come here and I don’t think you’d get as much out of the C.I.O. role.

The more you can find that, the better. You’re not necessarily going to find it all in one package. The fact that I’ve been in health care for 25 years is a tremendous benefit that you may not be able to find. In some areas, maybe your Chief Digital Officer coming from the retail world without any health care experience helps because they’re not jaded to the environment. For my opinion as the core head technology leader, having that experience, knowing that business and being able to think like an operator as well and then, that put with the balance of funding with value, balancing around operations – giving and taking what matters, becomes important.

I could say, “Give me a hundred million dollars for security. I’ll make you more secure.” So, are you going to be – “Is that really going to pay off? Is making you secure enough to justify 100 million? What is the balance of that pragmatic approach to leveraging tech?” The analogy in a business, and I think, that’s what a C.I.O. needs to be in the environment and stay as effective as they can.

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Disclaimer: This Q&A has been derived from the podcast transcript and has been edited for readability and clarity