Author: arpita

Digital isn’t just about new care models but enhancing traditional care models through digital means

Episode #37

Podcast with Angela Yochem, EVP, Chief Digital and Technology Officer, Novant Health

"Digital isn’t just about new care models but enhancing traditional care models through digital means"

paddy Hosted by Paddy Padmanabhan

In this episode, Angela Yochem discusses how Novant Health, a $5.5 billion nonprofit integrated healthcare provider network based in North Carolina, focuses on improving care quality for consumers through advanced technologies. She also discusses her current role and responsibilities at the organization and how digital health is much more than digital front doors.

At Novant Health, digital care is not just about new models of care delivery using digital tools. It is also about enhancing traditional models of care delivery through digital means. Angela, along with her team, provide advanced digital capabilities to improve the quality of care for patients and community members and ensures increased access to care through digital means.

Angela believes that healthcare organizations must adopt contemporary methods and technologies to improve patient engagement and care delivery. However, this opportunity is closing rapidly due to the emergence of unconventional entrants in the healthcare ecosystem. In the podcast, she discusses how she and her team have developed approaches to identify and rapidly onboard innovative digital health solutions for high-impact areas such as stroke care. She advices health systems leaders to bring in people from outside of healthcare for diverse perspectives to solve the most complex problems.

Novant Health, Chief Digital and Technology Officer, Angela Yochem in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “Digital care is about care delivery and enhancing traditional care models through digital means”


PP: Can you tell us a little bit about Novant Health and your role and perhaps also touch upon your unique org structure?

AY: Certainly. Novant Health is a $5.5 billion nonprofit integrated healthcare provider network. We have 15 major hospitals. We have between 650-700 clinics and physicians centers and about 30000 team members. As you can imagine, we’re focused on meeting our consumers’ needs by shaping new services and experiences that resonate with our consumers and the communities that we serve. Technology advances drive a lot of those expectations that our consumers have and certainly change the way we think about engaging with our patients. And, of course, our team members and the border communities. My position was added in late 2017. It was meant to provide a way to increase access to care through digital means and also to define how we can improve the quality of care by leveraging advanced technologies. And, of course, our unprecedented access to data that we enjoy in the healthcare space.

My teams, of course, helped the organization explore many ways that the digital capabilities that we provide can improve the health and the lives of our community members. I’m fortunate that I work for someone I would describe as a digital CEO, Carl Armato. This notion of a digital CEO I think is something that’s so important to so many industries today. Digital CEOs understand that advanced technology functions are essential to providing differentiated services and products regardless of industry and that the executive team for any company must have expertise in the tech field represented at the decision-making table so that they can identify those opportunities when they emerge. In my organization, we moved all of the roles, all of those related roles report to me. And that, of course, helps us reduce fragmentation and avoid conflicting investments or duplicative investments and technology and analytics space across the board. So my senior staff includes a Chief Information Officer, the Chief Technology Officer, our Chief Medical Informatics Officer, our CISO for cybersecurity, our Chief Data Officer and the Chief Digital Health and Engagement Officer, as well as an executive responsible for learning and research across the Digital Partner Services Group, which I believe is a strong, cohesive team of highly talented people from a variety of industries in a variety of backgrounds and credentials area. It’s been incredibly rewarding.

PP: There’s a fairly impressive set up there and we’ll talk about some of the initiatives that you mentioned. Novant Health is based in North Carolina. Is that right?

AY: It is. We’re headquartered in North Carolina. We operate primarily in three states and we have a footprint across five. And I guess what you’d call a super-regional.

PP: Angela, you came from outside the healthcare industry. What struck you the most when you came into healthcare and into this role? What is your assessment of the current state of maturity of digital transformation and digital health in the sector?

AY: Those are two very interesting questions. What struck me when I came here and in fact, one of the reasons I joined Novant Health is that the significance and the importance of the work being done in Novant Health, I mean, literally life and death work, right? Drives a tremendous appetite for adoption of the latest and greatest capabilities that would allow us to provide higher quality care, greater access to care, get better outcomes for our patients and communities. So, it’s that appetite and that ambition for improvement across the board and a passion that I think our team members bring, our clinicians bring at Novant Health that struck me that is so different than what I’ve seen in other industries. I had an opportunity to work with very, very smart, driven, amazing people across the other industries. But the life or death aspect of what it is that we do here just elevated that intensity and I’m the type of person that appreciates that intensity. So that’s one difference that I saw that I really appreciate it.

The other thing I’ll say in response to the second half of your question is that healthcare organizations have an opportunity to adopt more contemporary methods and technologies and architectures and philosophies related to engagement and the delivery of solutions sets to consumers and team members. And I’ll add that the window of opportunity for adopting more contemporary capabilities is closing rapidly. And I would say that based on the number of unconventional entrants that we’re seeing in the healthcare ecosystem.

PP: Defining digital health in terms of just digital front doors, is that too limiting? Should we be thinking about modernizing technology to your comment about bringing in contemporary technology and therefore expanding the scope of digital transformation? How are you defining digital transformation in your role?

AY: This is a fantastic point that you raise. Thinking about digital front doors and only that as being the scope of digital engagement is of course very, very narrow. At Novant Health, we define digital care in both the ways in which we use digital channels to offer care, which is what you’ve just described, but also in the ways in which we enhance our traditional models of care delivery through digital means. You see a lot of investment across the investor community in point solutions that are allowing us to provide as we adopt them. Unprecedented access to care using devices such as our on-demand TytoCare visits or, the ICU capability, tele-behavioral health, kiosks, and remote locations, community centers, and schools. All of these sorts of things are highly visible and they’re absolutely a real thing and a real focus area for us as well as for everybody else.

But to your point, we also focus very relentlessly on capabilities that increase the quality of care. I’ll give you a couple of examples. Earlier in 2019, we launched across all of our hospitals a stroke care solution. I’m sure that your listeners know what happens when a patient exhibiting stroke symptoms shows up in emergency department. But just for those who don’t, I will describe it very briefly. A stroke patient shows up, an emergency department whisks them back, puts them in a CT scanner. They get into a CT scanner, CT scanner runs. And then once the scan is complete, the images examined by the radiologist on call, who in turn might pass it along and see something that may need some care, some attention, will then pass along to the physician on call who then engages the neurosurgeon on call and somebody at some point ready for the operating room. And if there’s some sort of operable occlusion, the patient is treated in that operating room. My understanding is that the national average is somewhere in the mid-50s of minutes. So, between the time when the patient shows up to the time when the operation is being conducted, and if you think about a stroke patient losing a couple of million brain cells a minute, give or take, that’s a lot of minutes. It’s a lot of brain cells lost. So, we have partnered with a third party called Viz.aI who receives the CT scan data while the scan is still being conducted. So as soon as the patient goes into the CT scanner, in any of our hospitals, we stream the data into the Viz.aI environment and they apply AI-based algorithms to the streaming data as it comes through and they can identify an operable occlusion if it exists well before the scan is complete. And so, their solution actually sends the scan to the neurosurgeon on call and makes a notification to the OR so that we have treated patients in as few as 14 minutes from the time they show up to go and see department exhibiting stroke symptoms. Big deal. Our average amount of time with this AI solution in place is about somewhere between 22 and 25 minutes. Well below the national average.

Now coming back to an important point, between the time when we learned of the existence of this type of solution and the time we had it in all of our hospitals, its four months. So, it’s not just about adopting solutions that are truly life changing, life saving for our patients. Increasing the quality of care in this example in the stroke protocol. It’s also about preparing the environment so that you can adopt rapidly these sorts of solutions without the traditional sort of year-long analysis phase that might go on otherwise.

PP: Can you share any early learning, any data points that could benefit our listeners and all those who are implementing these kinds of tools for improving patient engagement?

AY: Absolutely. One of the things that was so interesting when we launched this digital health and engagement division, which is led by a practicing family physician and a strong team of people from a variety of backgrounds, is that the appetite in our patient community is so strong for helping us as we develop these solutions. Our strategy for everything we do at Novant Health starts with the patient. We want to know how we can eliminate their pain points, what do they need, how can we change to meet those needs, and so on. So, when we announced the creation of this division, we ended up having 7500 patients sign up to be members of this group we call ‘community voice’. So, this is a group of patients, community members, and caregivers who’ve agreed to be our focus group and sometimes a pilot group for new digital capability.

So, the learning that I would pass along to others is the appetite exists. And you can have a very, very large sample set of participants as you run experiments with new ways of engaging your patients digitally. I think you have to figure out how you’re going to manage that community, which we’ve done and obviously which can be done. It’s been a wonderful success. And the most recent example I’ll give you is our exclusive partnership with a company called TytoCare.

So, it’s just soft launched in North Carolina and it’s for On-Demand remote medical exam. We’ve had On-Demand video visits forever. TytoCare is a device that’s about the size of the palm of your hand and it has a variety of peripherals that plug into it. And these devices, when used by patients or caregivers, allow them to connect with a Novant Health provider who can virtually examine the heartbeat, the lungs, look at the breathing, look at the skin, look in the ears, look down the throat, look in the eyes, look at the nose, check the abdomen and so on, from wherever they are. And all of these examinations are not only being guided by remote provider but in the case where a patient might want to do the self-exam without a provider live, then the device itself will guide the patient through the process, analyzing the signals coming in from the advanced sensors and the device in real-time and using those signals to tell the patient how to adjust the device.

For example, if your patient is trying to capture a picture of his or her own eardrum, then the device will guide the patient until the image of the eardrums is collected and then it’s automatically, immediately saved in the electronic health record for that patient. So, a really interesting advancement in providing access to care. For anybody who’s ever had a child who suffers from multiple ear infections, if you can imagine, 10:30 at night your child exhibiting ear infection symptoms, wouldn’t it be great not to have to worry about taking off work the next day and trying to get the child an appointment and instead allowing an exam to happen right then, having the ear infection diagnosed right then and having the prescription called in right then and the child gets to start taking the treatment immediately before even going to bed that night. So, this is the sort of thing that the team is working on and doing some fairly groundbreaking work in our region.

PP: You’ve had great success in having your patients engage with the digital tools that you’re putting out and have thousands of patients sign up and be a part of it, willing to participate. Now you’ve got a self-triaging kind of a tool through the TytoCare device. So, it seems like that is a recurring theme that you’re getting patients engaged in their own care instead of having to push it out to them. And you’re getting a fair amount of success in the virtualizing care through advanced technologies. Am I getting it right? Would you agree with that assessment?

AY: I do agree with that assessment, but it’s a journey that goes on constantly. So, this is not a space in which we can rest on laurels. This is not a space that remains stagnant by any stretch. We have to continue to adjust to emerging patient expectations, the needs of our communities as they evolve. And those are the sorts of things that I think keep us on our toes. And that’s why we built these constructs that allow us to continually look for these opportunities and run experiments with some of the technologies so that we understand what the impacts would be and how to prioritize the work.

PP: Can you talk a little bit about what your goals are for the Institute of Innovation and AI and how you are harnessing data to drive these improved experiences? Talk a little bit about the institute itself and the goals, if you could.

AY: Sure. So, we launched the institute this past year. I co-founded it with Dr. Eric Eskioglu, who is our Chief Medical Officer. He happens to be a practicing neurosurgeon and before he was in medicine, before going to medical school, he was actually an aerospace engineer. So, he’s a rocket scientist. So really great partner to have as we think about things related to innovation and artificial intelligence and other advanced technologies that really need never be explained to him. He’s always there as a tremendous partner with me, as a digital leader. So, when we launched the institute, the goal was to identify these technologies that may not even be commercially available? How do we use them to accelerate solutions that allow us to provide the highest quality, highly personalized care.

The constructs allow us to work with our very engaged physician community, as well as other team members from across the system and partner very easily with a variety of third-party types. We partner with members of the startup community. We partner with universities and other research organizations, other healthcare organizations. A variety of unconventional partnerships tend to be crafted as part of the work that we do inside of the institute. And ultimately, this allows us to run rapid experiments with new solutions that understand impact based on real data that we can collect, not just, suppositions, better engage the broader community inside of Novant Health to get involved in making these game-changing advances for our patients and in our practices and also to best manage investment so that we’re not a naturally fragmented in the sorts of experiments that we run across the board. It’s been a great success in the sense that we’re able to do the work rapidly and with a feeling of having the right experts in the room at the right time.

PP: Can you give us the State of the Union on data interoperability and how are you really harnessing all the emerging datasets that we’ve talked about? We tend to talk a lot about EHR data, but there’s so many other emerging data sets. How are you actually harnessing the data for all the insights that you can potentially generate or some of your programs? Can you talk about that?

AY: Let’s break this down a little bit. So when we think about the broader state that we manage, what are our assets? What do we bring to the solutions that we define for the toughest problems that we’re facing in healthcare? Data is one of those assets. We have patient clinical data. We have consumer data. We have behavioral and trend data. We have our business’ master data. We have a variety of data from many, many sources. We have to have a place where the data can reside and we can apply functional capability to it.

Functional capability is expressed through a variety of solution sets. Some are homegrown, others are provided by various third parties. As we’ve discussed already, we have digital assets that provide care and other access related capabilities to our patients and our communities. We have capabilities that support the running of our business and other foundational elements. Many of these capabilities can and should be provided by a traditional healthcare vendor like an EHR vendor. It is about about data. It’s best for us to focus on creating an architecture that can allow for interoperability between solution sets and various third parties in a highly secure fashion. That’s how we get the most out of the unprecedented access to data that we have. This is what’s going to allow for rapid adoption of potentially differentiating services for our patients. This is what leads to that extreme personalization in all engagements with patients improving the quality of their care through faster diagnosis, breadth of treatment options and of course all the other advanced tech that we can apply to it.

With such extraordinary availability of data and the things that we know we can do within the existing constraints, and within our existing agreements that we have that patients for the usage of the data. We are watching with great interest this debate and the deliberations that are ongoing. And while I don’t have direct visibility into how those considerations are playing out, my hope is that the eventual ruling will benefit our patients. And meanwhile, the things that I can control are the architectural choices that I just mentioned. As long as I stand ready to be as interoperable as possible and as secure as possible across the board, then whatever the decision is, we will be best positioned to serve the patients and communities.

PP: Digital programs, in general, are in early stages of maturity and there’s a long way to go to your point earlier that it is a journey that is by no stretch it’s all done kind of thing. So how do you actually keep track? How do you measure progress? How do you keep score of whether a program is working or not?

Well, so we look at outcomes fairly consistently across the board. So, we measure the quality of our care through a variety of mechanisms. We measure the access to care, the ability that patients have to access care at Novant Health. We in the digital channel space have all of the usual measures that other industries have been using for engagement, for digital engagement, and we certainly track that because we are a business and we’re a rather large business. We track how we can continue to provide advanced capabilities to our patients and community still within an acceptable cost structure.

So, all of those sorts of things are measured as you’d expect them to be. I think that is the most important thing that is specific to digital capability to be able to measure and track progress. The nature of how we’ve defined progress outside of these broad buckets that I just mentioned would be different from case to case. But measurement is one of the most important things we can do post-launch. You’re not done when you’re launching a product or a solution. You are never done. The incorporation of the measures and the results that you’re getting should always feed into the next decision cycle and in our case that has a relatively short window of time.

So we continue to iterate on all of the services and products that we deliver to our communities as well as to our team members inside of Novant Health. As we think about how we are acting as stewards of the resource that our companies have that are so important to us ultimately to the health of our communities.

PP: Any final thoughts that you’d like to share with our listeners as it relates to how they could be looking at their digital programs or anything from your own experience as a best practice?

AY: One of the things that has been such an accelerator for us here is the creation of the chief data officer role and corresponding organization, which include the Cognitive Computing Group, which includes Enterprise Information Management Organization. These sort of constructs and the corresponding investment that allowed us to accelerate some of those foundational capabilities t are absolutely required in advance of being able to do any of the more exciting things we’ve talked about that are more functional in nature.

So, getting those foundations right is important. That doesn’t mean you have to take a couple of years to do it. It has been done in other industries. My advice to other healthcare systems is unless you are in need of additional health care expertise, don’t be afraid to pull people in from outside of healthcare because it’s a gift to allow them to participate in such a wonderful industry. And it will be a benefit to the industry to have diverse perspectives involved in solving some of our most complex problems.

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

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

About our guest

Angela Yochem is EVP, Chief Digital and Technology Officer for Novant Health, a super-regional healthcare system with one of the largest medical groups in the US. She and her teams deliver the world-class consumer capabilities, differentiating technologies, and advanced clinical solutions that allow the high-growth system to provide remarkable patient care.

Angela has served as EVP/CIO at Rent-A-Center, Global CIO at BDP International, Global CTO at AstraZeneca, and divisional CIO at Dell. She’s held tech exec roles at Bank of America and SunTrust and held senior technology roles at UPS and IBM. In these roles, she built B2B digital product lines, grew digital retail channels (B2C), created technical services lines of business, and transformed global technology capabilities.

Angela has been a Director for the Federal Home Loan Bank of Pittsburgh, BDP Transport, BDP Global Services Asia and Europe, and Rocana, with experience on Audit, Enterprise Risk, Operational Risk, and Governance/Policy committees. She remains an EIR for Vonzos Partners, a Mentor for SKTA Innopartners, and an Advisor for Dioko Ventures. Angela serves on the board of Freedom School Partners, a non-profit committed to promoting literacy in the Charlotte area, and on the executive team of the Go Red for Women organization, part of the American Heart Association. She is a Trustee of the Charlotte Regional Business Initiative and is an advisory board member for the American Hospital Association Innovation Council and the University of Tennessee Electrical Engineering and Computer Science department.

Angela has a Bachelor of Music from DePauw University and a Master of Science in Computer Science from the University of Tennessee, holds three US Patents and is an author with Addison-Wesley and Prentice-Hall.

About the host

Paddy is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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Every patient has a right to control where their health data goes

Episode #36

Podcast with Paul Black, CEO, Allscripts

"Every patient has a right to control where their health data goes"

paddy Hosted by Paddy Padmanabhan

In this episode, Paul Black discusses the next wave of opportunities for Allscripts and how digital transformation is shaping the healthcare sector. Paul also discusses emerging technologies and how Allscripts has embraced cloud adoption for many of its solutions. He believes that emerging technologies such as AI, Blockchain, and voice recognition are improving patient experience, driving better healthcare outcomes, and substantially enhancing the physician’s life.

In the context of the ongoing debate about patient data access and the proposed ruling by the HHS, Paul states that Allscripts strongly supports legislation or regulations that address information blocking in healthcare. He suggests that health systems, looking to harness innovation, must bring together outside help with industry experience and their own organizational knowledge from a clinician standpoint to accelerate transformation.

Allscripts CEO Paul Black in conversation with Paddy Padmanabhan, CEO of Damo Consulting on the Big Unlock Podcast – “Every patient has a right to control where their health data goes”

PP: In terms of technology for the healthcare industry, what do you see as the next wave of opportunities for Allscripts?
PB: Allscripts has done a lot of work over the last 25-30 years to get the entire platform, especially in the United States, to be completely digital. It is a very exciting place for Allscripts to be in especially from patient safety standpoint, from our capability to have efficiencies and just to ensure better patient care and better patient access to that care. Also, the digitization of patient records enhances the ability for health systems to deliver care protocols in rural areas just as they deliver care protocols in a large academic medical center in a large populated urban area. This is transformational, and in a transformed environment you are actually going to practice medicine differently for the rest of your life. So, from here, going forward, we’ll never go back to paper. We’ll never go back to the way we used to do it. The entire platform has been not only digitized but transformed. So, again, we look at that and we see a lot of opportunities for that going forward.

PP: So, Paul, you mentioned transformation. Everybody talks about digital transformation. Do you have a definition for it at Allscripts? What do you see as big themes playing out in the name of digital transformation today?
PB: There are three or four things. We have, in many cases, tried to anticipate where the industry is currently so that we can have platforms that are relevant to people that are doing business in a transformed and digitized area. So specifically, around interoperability and population health, our definition around digital transformation has to do with the ability to take a vast amount of data from multiple different electronic medical record organizations and companies to give a unified and community view, a single view, of that patient’s information. We’ve been doing that for quite a while now. And I think that’s an important construct that you have to have which is foundational.
Infrastructure has to be in place because no one is ever going to get to one record. You are always going to talk to the state, you are always going to talk to insurance companies. People have different electronic medical records or other information systems that have clinical information in them that are relevant to that individual person who has a condition that you’re trying to help them recover from. So that’s one.
The other one that I think is important, is the consumer. We all have talked about the concept of a patient being a consumer. Unfortunately, the status they have as a human being is defined as one who has become sick, met an accident, or some episodic condition that they have been battling for many, many years. But the consumer, is somebody who proactively looks for and shops, compares and writes, and, you know, is really actually very actively is engaged in the buying process. And specifically then for us in healthcare, the consumer is somebody we have to really be aware of and what their patterns are, what their likes and dislikes are, how they like to be treated, how they like to access the health system and what kind of requirements they have when they are on their smartphone or their iPad. What are the services they are looking for that weekend, that night, that evening; where they can quickly go in and get certain mobile care.

PP: What is your take on the debate that’s going on today with regards to providing access, specifically the HHS proposed ruling around providing access and where do you think we are today? Is this something that you see being resolved in the near term or do you see that being an ongoing concern?
PB: The regulations that are out there and being proposed are going to be distributed very quickly, I think. We actually have been very heavily engaged in this process going back to the 21st Century Cures Act. I think it is about going back to a very foundational and important pillar inside the EHR community. We have a very important voice in Washington, D.C., and on multiple different topics I’ve had a chance to testify in two separate congressional hearings on the topic.
We met two months ago with HHS Secretary Alex Azar and Joe Grogan. Joe is the White House Director of Domestic Policy. We had discussions in this specific area and the specific arena, and there are a lot of things that we really like about it. There are just a few things that we asked for some further clarification around intellectual property protections, market-based pricing models for information exchange, and the appropriate scope of certification requirements. They’ve been very good about listening and have been very considerate of the feedback. We’ve had a very constructive dialog with them on those topics.

PP: I heard you say that there have to be some guardrails around how the access is provided in order to protect patient data. Did I hear you right?
PB: Yes, you did. The guardrails are already in place that we are adhering to. Anybody in this industry has been extraordinarily cautious about and respectful of the laws that are out there for all the good reasons. Specifically, on this one, going back to the regulatory environment, we have never advocated against legislation or regulations that address information blocking in healthcare. We strongly support that and have been part of this open infrastructure ecosystem since 2007. It’s interesting that same year the iPhone came out too.
We believe that people should have access to the data and that system should be much more open at an API level, which the legislation also requires more than just the HL7. FHIR also been very important in that area. But we also believe, importantly, that every patient has a right to control where their health data goes when it moves or doesn’t move, and who sees it. And so, we actually grant consent at the patient level with our consumer platforms. We have been advocating for that, and that was one big piece of this legislation that we were extraordinarily supportive of. We’ve always been encouraging of the legislation to give the patient full control of their patient medical record.

PP: Where do you see are the big use cases for AI, machine learning, advanced analytics in your work and in some of your clients?
PB: There’s been a fair amount of work that’s been going on for a long time. Over the last two or three years, AI is getting a lot of attention for things like Watson and some of the other big players that are out there using artificial intelligence for cancer, or radiology. They are using it for the substitution of a human to be able to look at certain data patterns and to come up with a different answer or a better answer and a more efficient answer. So, I think those are a couple of examples of the way the people are looking at it today. I think that there will also be, from an efficiency standpoint, a lot of artificial intelligence utilized for that.
The other piece of data that comes in is when you’ve automated the shop for healthcare. Not only do you get clinical information in real-time, but you also get consumption information in real-time, such as how efficient organizations are about moving patients through the system. Will that be the ED wait time? Or components like that all the way through how many resources were consumed in order to do a certain specific surgery and how much time it took in the overall costing of that? I think it’s going to be a lot of fun to track. What we like a lot are the capabilities once the data is stored, structured and now we have to study it, but also to use the data crawlers and some other capabilities that exist out there to give us new insights about populations that we can go then put specific programs around.
When you think about it, you’re financially responsible for a large community of people. That’s one element at the big data level that I would look at. By big data, I mean you’re looking at multiple hundreds of thousands if not many people at once and you’re looking for specific conditions and specific precursors of that disease warning signals or flares or other weird events, that if you follow closely, you might be able to prevent the further deterioration of that patient. Whether that be COPD or cancer or some other areas that are out there.
So, I think those are all capabilities that exist today that I think are exciting and those are capabilities that many different organizations are getting much, much better at utilization.

PP: Do you think we are seeing more benefits from non-medical use cases of AI than in the actual practice of medicine?
PB: I probably would not agree with that. There are equivalent use cases for the financial information around HCC coding, around appropriate billing, around the financial side of healthcare. Anytime you look at large rooms of human beings that are staring at screens and are punching away on their keypads – I think there’s great opportunity for that. But I wouldn’t necessarily say that overreaches what the clinical benefits are in the clinical usage of those systems are today. But I do think there is a substantially large amount of that.
Things like blockchain are probably, at least currently, best suited inside of financial elements in insurance companies and other things inside of healthcare that makes it a great tool. But there’s also the clinical side of blockchain, another great example of that use case would be Medrec. Medical reconciliation of all the different medications that people are on would be a perfectly well-suited application for a blockchain. And it’s a big, big opportunity.
It is also a big problem if you do not properly understand every single medication that a person is on. And unfortunately, many times, the number of medications that people are on, they don’t really remember everyone that they’re on either. Therefore, as a pharmacist, you are engaging with a bunch of different systems at once – the consumer side, the hospital dispense, the local pharmacy dispense, the mail order, and making sure that all of those medication administration records tightly fit together and they all have a ledger approach with which blockchain can lead a very simplistic way to be able to make that happen, which is pretty exciting.

PP: Can you comment on where we are with voice recognition and specifically may be what you’re doing at Allscripts to incorporate voice into your solutions?
PB: Voice recognition has been out there for the last 25-30 years, especially in radiology departments. It has been great. And, probably on a scale of 1 to 10, 10 being finished, that’s probably somewhere at a 9. So, there is the ability for voice recognition to replace a keyboard, substantially enhance the physician’s life.
There is a lot of experimentation going around taking that technology and extrapolating that and using it into a very busy primary care clinic and having the caregivers being able to talk to a device that’s in that room and not have their hands on a keyboard. We call that the keyboard-less visits. And we have clients that are working on that today at scale and they’re getting a lot of value out of that. They’re clinicians like that, because anything that takes them away from having to hunt and peck on a computer keyboard, they’re all in, especially when you’re trying to see 40 to 60 patients a day. It really can help compress the amount of time that they’re spending, doing documentation. Chart reviews and other things like that in advance are still needed. But that’s another very important use case. I think that will only continue to enhance the experience that clinicians have and the usage of will continue to be accelerated outside of radiology into almost all areas of the practice of medicine.
That’s certainly the work that’s going on between Microsoft, Apple, and Amazon on this topic and will highly accelerate the efficient and clever uses of the technology that has been out there since the 80s and perfected, about 20 years ago for radiologists. Voice recognition needs to be moved into mainstream clinical care.

PP: Do you see keyboard-less technologies, such as identity and access management for patients through facial recognition, picking up as well from an emerging tech standpoint?
PB: Yeah, there’s a lot of different ways for people to log in, which is another problem. But the two-factor authentication is needed from a security standpoint. And that requirement will be out there, especially for medications, the narcotics, and other controlled substances that are out there. And so, the ability to navigate and identify a person through a palm, a fingertip, a retinal eye scan are capabilities that exist today. It will continue to get better and easier for caregivers to get through who you are. That will form a very important part of the process of being logged into a system.

PP: We’re seeing a lot of cloud data sharing agreements. Where do you see us today in terms of cloud adoption in healthcare? And where do you see the big opportunities?
PB: We have a number of our applications that are a native cloud today. We have other applications that are moving to the cloud. There’s no question that this technology is being rapidly embraced by and adopted throughout healthcare. I do think that they are a bit of a late adopter, but that doesn’t mean the acceleration of that adoption can’t be substantial as compared to somebody that might be in the cloud in other industries 10 years ago.
So, number one is that it is not only coming, but it’s here. And as recently as three years ago, we do business in other countries, a national policy minister for health stated you could not have patient data in a cloud infrastructure. Today, it’s encouraged and considered an extraordinarily important move. For people like us that have applications whether it’s an EMR or other solutions that are out there, that opens up a lot of opportunity. So, from our perspective, the benefit of having something in the cloud is somewhat obvious. The ability to ubiquitously access this data from any device, to have a different, and more robust layer of security, especially when you think about the investments that these organizations – Amazon, Google, Microsoft – make every year in the digital infrastructures and the cybersecurity surveillance capabilities, they dwarf the investment that a large integrated delivery system could ever make. I think that will be one of the more compelling reasons why people move to the cloud.
The third reason would be that the total cost of ownership, not having to do upgrades, not having to buy hardware, not having to have your own local backup data centers, all of that goes away with the transition to the cloud. And therefore, the total cost of ownership for an institution as they look at being able to have a different utility that provides those services to them. While it may not be the total parity today, there’s no question in my mind that over the next decade that service will be performed and that the competition between those organizations, like any other technology, will eventually drive that cost down to a point where the cloud will not only be affordable but extraordinarily attractive.

PP: How are you harnessing digital health innovation in your own product portfolio? And what is your recommendation for health systems that are struggling to do it in a way that doesn’t break the bank?
PB: Well, there are three or four things, I guess I would say. Number one is the fact that when we talk about being open and connected, that we build open, connected communities at health. The word “open” is really important, it’s not just a buzzword. In our ability to not only have that as a culture inside the company but how we build our solutions and the access that we grant third parties to relatively deep level APIs, is an important construct that distinguishes us from other people that have been in this industry as well. Part of that open framework for us creates an incentive for startups to utilize our platform and to partner with us to build their business case, their business model, and to take their innovation into a welcoming environment where they can prove out and test cases, but also get access to clients that are already connected to a network and potentially gets to scale much more quickly. So, we encourage that. We fund some of the people that we work with. We see a lot of different companies. We have over 279 different companies that have written applications that sit on top of our solutions. We have clients that have written their own and sit on top of that environment, that ecosystem that we’re trying to create to support entrepreneurs and support innovation. It has been something that I actually inherited when I first got here. In 2013 we gave out that are in the user’s group a million dollars for the top four applications that have been developed and that sat on top of our ecosystem. So that’s something we’ve got. It’s not a lip service, we actually embrace it and we support it. We have people that are dedicated to helping those folks become successful.
Clients, many of them are building a capability inside their organization, especially large ones, where they have a JV fund, where they’re actually looking for and then putting money into third parties, entrepreneurs who are building applications and have already declared startup status. There are a number of large organizations all over the country that have this business line of helping fund venture capital-backed organizations that are building and innovating new platforms inside of healthcare. There’s a lot of that activity and I like that, and I encourage that, and again, to the extent that those applications that are funded by JVs and supported by large integrated delivery networks are also part of the Allscripts ecosystem. We just think that’s a wonderful, wonderful way to bring innovation to healthcare in a much-accelerated manner.

PP: What is your recommendation to health systems that are looking to harness all this innovation? How should they go about accelerating the adoption of innovation? What are some of the best practices that you’ve seen?
PB: I think organizations like University Hospitals in Cleveland, Northwell, Ascension – all have these funds that are set up and they act. They brought in somebody from the outside typically who had background experience in investing in joint ventures that combine them with the organizational knowledge of what kind of solutions actually would work in that kind of experience from a clinician standpoint is a pretty powerful combination. I’ve got people that know what problems I’m trying to deal with today. I got people that know how to look for, search out and procure dollars and to find the companies that are building things. The combination of those two with them, the ability to immediately inject that solution into a relatively large ecosystem, their own caregivers make it a very powerful combination.

PP: Paul, any closing thoughts? Anything exciting planned for HIMSS that is around the corner?
PB: We love HIMSS. We like to have a lot of people there. A great place to meet a lot of clients, suppliers. We actually do a fair amount of recruiting there. We talk to analysts, both people that follow the industry. We talk to a lot of people that write about the industry, folks like yourself. So, it’s a very efficient way to spend three or four days. We will highlight some new capabilities that we have down there, which is always kind of fun. Talk about the innovation that Allscripts brings to the table and also a fair amount of putting exclamation points around some of your clients’ experience and some of our clients’ success.

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

About our guest

Paul Black is the Chief Executive Officer and a Director of Allscripts. As the CEO, Paul guides the company’s vision to fulfill its global commitment to build open, connected communities of health.

Prior to joining Allscripts in 2012, Paul spent more than 13 years with Cerner Corporation in various executive positions, retiring as Cerner’s Chief Operating Officer in 2007. Paul’s career started with IBM Corporation where he spent 12 years in a variety of leadership positions in sales, product marketing and professional services.

Paul has served on multiple publicly traded, private company and nonprofit boards of directors for companies in healthcare information technology, patient monitoring, healthcare services, healthcare delivery, healthcare device, and consumer internet marketing.

In Kansas City, Paul spent 16 years as Chairman and as an Executive Officer of Truman Medical Centers, an academic safety net health system. He currently is on the board(s) of The Advancement Board University of Kansas Health System and the Harry S. Truman Presidential Library. Paul holds a Bachelor of Science degree from Iowa State University and an MBA from the University of Iowa.

About the host

Paddy is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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We give hospitals the ability to quickly and securely send patient records to outside clinicians

Episode #35

Podcast with Dr. Peter Tippett, Founder and CEO, careMESH

"We give hospitals the ability to quickly and securely send patient records to outside clinicians"

paddy Hosted by Paddy Padmanabhan

In this episode, Dr. Peter Tippett, one of the first person to develop a commercial antivirus software, discusses how careMESH is providing easy and secure communication and collaboration between clinicians locally to share digital patient records. Peter also discusses the issues related to information security in healthcare.

Healthcare, like in other industries, requires digital communication in everything, be it care coordination, patient safety, reducing readmissions, unnecessary ER visits, or analytics. To address this marketplace requirement, careMESH makes a set of national secure service that helps health systems to easily communicate about patients and share patient records from their own EHR to any outside physicians/ clinicians, reducing the time consumed by traditional communication ways within health systems.

According to Peter, health systems have started investing in and adopting digital transformation to provide ‘virtual health’ through their own EHRs, EMRs to provide care coordination, social determinants, and enabling home health workers for patients. These health systems are the powerhouse, incubating the innovative startups and providing them the focus they require to make the change happen in healthcare.

Welcome to The Big Unlock podcast where we discuss data analytics and emerging technologies in healthcare. Here are some of the most innovative thinkers in healthcare information technology talk about the digital transformation of healthcare and how they are driving change in their organizations.

Paddy Padmanabhan: Hello again everyone. Welcome back to my podcast. This is Paddy and it is my great privilege and honor to introduce my special guest today, Dr. Peter Tippett, Founder and CEO of careMESH. Peter, thank you for joining us and welcome to the show.

Peter Tippett: Thank you so much. It’s a great privilege.

Paddy Padmanabhan: Thank you. So, Peter, you have a very interesting background. And among other things, you are also the first person to have developed a commercial antivirus software. So, tell us how all that came about.

Peter Tippett: Well, I was one of those tech engineering nuts even when I was a teenager. I was a ham radio operator and a commercial radio engineer and a pilot. I was one of those couple of kids that were allowed in high school to touch the 55-board teletype locked in the closet. And in college, I stumbled into more things. I used a very similar computer in a lab doing really early cholesterol and Hyperlipidemia work. And I used it to automate their analysis and results. And then for my college seasons, I wound up as an apprentice and an assistant for two different Nobel Prize winners. The first guy sequenced the first protein and the second guy, Bruce Merrifield, synthesized the first protein. And I was there, you know, and used computers in his lab to automate that whole process. And along the way was the first guy to synthesize an active immunoglobulin. And of course, all of that got me a scholarship for an M.D. Phd at Case Western Reserve. And then when I was at Case, I was President of the Cleveland Computer Club. I started a software company in my attic trying to do other sorts of things. And when the virus problem came along, I created the first commercial antivirus. It was called Vaccine, but eventually changed its name. We wound up in a booth a few booths down from Steve Jobs at the West Coast Computer Fair. We grew that company, which was called Certus, for a couple of years before McAfee and the other guys came along and we sold it to Symantec and renamed it Norton Antivirus and then grew it in two more years past 300 million bucks. It was the big heydays that everybody likes to hear about.

Paddy Padmanabhan: Yeah. Well, Norton Antivirus. Now, that’s a household name almost.

Peter Tippett: Well, that’s a lot to do with those guys now of course.

Paddy Padmanabhan: Well fascinating story. I do want to spend a few minutes, given your background with software security and antivirus software and so on. I do want to spend a few minutes on this podcast talking about the current state of cybersecurity. You know, healthcare has been the target of cybercriminals for several years now. And my understanding is that it is the favorite industry for cyber-attacks. I read somewhere that the annual cost of healthcare data breaches in the region of four billion dollars and there’s no sign that is abating anytime soon. And four out of five data breaches are attributed to healthcare data breaches, and providers, in particular, are being singled out for these attacks. So, can you kind of break it down for us and tell us what the big issues are today as it relates to information security in healthcare?

Peter Tippett: Yeah, absolutely. Obviously, security is a huge subject. Maybe I can talk you into doing a whole podcast on it down the line. But, you know, security is hard, but it’s really not as hard as we all give it credit for. I’m kind of a scientist in this world and I spent a lot of energy over the last 20-30 years trying to get a sense of how the risk economics really work. And my biggest take home over the years is that we’ve really typically get talked into putting what my mom says is putting the emphasis on the wrong syllable. We have spent a huge amount of money and user equity on things that have very low marginal value and we ignore and allow the simple, inexpensive things that are relatively easy. For example, you mentioned ransomware. The basic solution to that is backup. Nothing fancy. Right. And oddly, using some of these newer information sharing services like my company’s new careMESH offering that gets some of your data accessible in other ways, all by itself is a mitigation for things like ransomware. If you look at the breach science and look at how that works out in risk dollars, there’s really just two things that reduce the overall costs and risk and likelihood of a breach by vast of the majority than all other things combined. The first one is a strong identity, despite what everybody says, making passwords stronger or more complex doesn’t do a squat. But adding a second factor like the code that comes to your phone or a token or whatever, that reduces risk by many, many orders of magnitude. So, turn those things on. That’s really simple. And it is really, hugely strong. The other thing is around network management. Running your own data server and data centers and firewalls and all that stuff is hard and expensive and we’re all error prone. But any one of the cloud providers has a hundredfold more security and ops people than any IT health organizations does. And you know, they have the experience, use the cloud and embrace it. Those are the key issues.

Paddy Padmanabhan: Yes. You know, just coincidentally this morning, I was on a Twitter chat with a group of cybersecurity professionals and a couple of things came out of that discussion. And these are very commonsensical type of things. The two big issues that the participants in the chat pointed out were, one, it’s a cultural issue, less of a technology issue, more of a culture issue. And really educating everyone in the organization at every level to be watchful of phishing attacks or to your point, turn on two-factor authentication. It’s a cultural thing. And so, you’ve got to have the right kind of culture to protect yourself against cyber-attacks. The second thing they talked about was in the context of healthcare the business associates are a big point of vulnerability. So, care to comment on those two observations?

Peter Tippett: Yeah. I mean, you know, the power is clearly in the hands of the attacker if you’ve got a million people and you can succeed at one percent opening a phishing email. That one percent is in trouble. So, a big attack surface is how we talk about that. But two-factor authentication works even against phishing attacks. The bad guy gets your password. So, what? Still doesn’t work. So really, really, you have to do both. Don’t spend all your energy worrying about one thing. You need seatbelts and airbags and then speed signs and all the others, and they all work together to really reduce things.

Paddy Padmanabhan: Yeah, OK. I kind of agree with you. We should do a separate podcast down the road just talking about cybersecurity issues. But for today, let’s switch gears here and talk about your company. Tell us about careMESH briefly, the company and the solution you’ve developed and what does a marketplace need you’re trying to address?

Peter Tippett: Yeah. Thanks so much. I’m a doctor. I spent most of my time doing emergency medicine and paying for all these startups by working at night in the ER, but I’ve long been frustrated that doctors can’t simply send a patient record to some other doctor or to some other clinic. It’s like we’re in the years before the internet ever came along. A huge hospital system client of ours reinforced that for me again lately. They worked at this giant referral academic center. They take care of 20-30 percent of their patients come from more than 25 miles away. You know, when they send those patients back home, half of those doctors get a two-page fax. And the other half get two pages sent to them in the US mail. I’m not kidding. The likelihood of getting a digital record outside of that 25 or 30-mile range is nearly zero. And this is not right This isn’t how the world should work. It drives the doctors nuts on both ends. It drives the patients crazy. Even the average hospital is not at that pinnacle of referrals to the world where two-thirds of their community doctors are using a different EHR than the hospital. Less than 20 percent of those outside doctors routinely get digital-only useful patient data. And almost none of them can communicate back and forth with a big hospital or the doctors or whatever. So careMESH came along to change all of that. We decided to make a set of global national, you know, secure services that don’t require complex IT infrastructure. So, hospitals can easily discharge patients or send referrals right from their own EHR to any physician or practice in the country and not make that other end, have to do anything or buy anything or even know who the heck careMESH is. Like when you send a FedEx, they came along with the idea, which was, give it to us and we’ll get it wherever it needs to go, even if it’s on some weird island somewhere that’s our problem. So, hospitals should be able to simply look up a patient in their own EHR enhanced by our national careMESH provider directory and push the send button or the complete button. So, hospitals can also automate the setting of detailed admission and discharge summaries, not just ADTs and PIDs without requiring the recipient to submit patient panels or log into portals or pull lists of patients or other things like that. So, careMESH is a solution like none other available in the healthcare industry, giving hospitals the ability to quickly and securely send patient records to any outside clinician. Of course, we want to completely embrace the new cloud, compute models and strong identity and modern high-end security and privacy and all that and make those problems go away as well as further participating hospitals. And any big platform can do a lot more than just sending records from hospitals or getting two-way communication going or keeping things digital. Because hospitals need to be able to efficiently share data outside their walls. Care coordination, patient safety, reducing readmissions, unnecessary ER visits, analytics, you know almost everything requires digital communication. So, we want to be complementary to the stuff that already works like HIEs and EMRs. But they just don’t work well enough.

Paddy Padmanabhan: So, it seems like there’s two aspects to what you’re trying to do. One is having a robust provider data management system, process platform where you can go to it as a single source of truth. And it really is the truth as it relates to providing data and then using the same platform or related functionality as a draw on the platform, you’re using it for care coordination, doctor-patient communication and so on and so forth. Am I right? Are these two broad components of your platform?

Peter Tippett: Yeah. We think of it as finding the doctor in the first place or the clinic. I want to send a message to Dr. Smith in Salt Lake City; the patient just knows Dr. Smith right. And figuring out which Dr. Smith and making that part easy from within your own EHR for whoever the clerical or clinical person is. That’s the directory problem. And then once you find the person making it so that just doing whatever you normally do. You know, a doctor’s order to discharge and a clerical person following up with the pieces need to happen to get the record out there or the doctor going into the messenger or the basket or whatever it is in their EHR and finding somebody that’s outside their building and saying, you know, asking them a quick question or something. That’s the directory problem. Then once you find the person, you want all the natural things to happen so that when you hit the complete button or the send button, they actually receive the message and it works. And it’s digital and it helps them at the other end as well. So that’s the delivery problem. Of course, it’s not as easy as all that you’ve got to HIPAA get going and compliance and interoperability and make it easy on the other end and make the reimbursements all happen. Big compliance and incentive payments from PI and all that stuff work. But yeah those are the main two components.

Paddy Padmanabhan: Yeah. Let’s talk about the competitive landscape that you operate in. Provider data management has long been an issue in healthcare. If I recall it right, it’s like a three billion-dollar problem or something like that. There are lots of companies trying to address it and using different technology. You know, there’s one aligned group of companies using blockchain, for instance, to create a single version of truth among other things. And everyone every doctor that I’ve talked to would love to have this single source of truth where they don’t have to keep on credentialing them again and again. They go to this one place where, you know, everybody has it all in one place, and it’s all a single source of truth. But it is a competitive landscape and lots of people are trying to solve this problem as well. At the same time, it comes to the other aspects of your platform, the care coordination, the messaging for the EHR vendors, Epic, Cerner, big tech firms. How do you see yourselves in this competitive landscape and what do you think makes you a little bit different?

Peter Tippett: Yeah. The technology like blockchain versus not seems to me to be pretty relevant. The most important thing is, as you said, figuring out how to solve, I call this “the surround problems.” I wrote one of the chapters in Ed Marx’s book on innovation – ‘Voices of innovation.’ And I know you’re working a little bit with him. What a great project you guys are working on. And it seems to me that things that actually get the job done when there’s a huge legacy installed base of things is not trying to fight the installed base, but trying to complement it to work within the system that’s already there and figure out how to extend it relatively easily. The trend of making programs to decide you’re going to blow up whatever is there and start over again is kind of crazy. So, if you can make a directory, you know, ours is FHIR enabled and it’ll work through a browser or a phone or any of that. But that doesn’t help the hospital. You need to make it so that it just becomes the natural directory that’s used by all the services that already use the directory in the hospital like your Epic in basket or the discharge floors or whatever. It doesn’t make that disappear so that no workflow changes happen. And then you’ve got the other issue. But when you get to the competitive things, I think of this as healthcare is wildly local and always has been. And the technology that follows it has been local as well. So, it’s been really easy to hire a big contractor and spend a million bucks hooking your hospital at the other hospital. After you spend a year planning and you’re doing in a year fixing, it works. But now you’ve got two points connected. Well, you know, if you do the math, there’s five thousand plus hospitals and two or three hundred thousand clinics. That would be two hundred three hundred thousand factorial connections and BAAs and all that. That’s by the way, more than our grains of sand on earth. So, this is stupid. This isn’t something that could possibly scale. So, what we need is analogous to what we got when we built the internet. We need a way that everybody can use the same network for all of the basics to not to find the other guy, but also to get something to them without file size limits or anything like that. We need something that works with the EMR vendors and the HIEs and extends their functionality naturally. And we need something that enables all the care coordination platform. I don’t want to build a care coordination platform. I just want to make the ones that are out there actually work for somebody who isn’t involved or some other end that didn’t buy the other end. Making everybody buy both ends of a fax machine or a telephone is nuts. That’s not how those industries evolved and ours can’t get there either.

Paddy Padmanabhan: So how do you build a business case? I understood what you said that you’re working with the existing technology stack solutions that are out there and making them better. So how do you actually build a business case? What do people look for when trying to justify investment in your platform?

Peter Tippett: Yeah. I was on the PITAC, the President’s Information Technology Advisory Committee. I know it’s going on 20 years ago with Baylor and that whole gang. And we said if health, you know, this is a triple aim, in my words, slightly. If health care could only use information technology in rough parity with, the banking or other industries would get three things right. We’d get wildly healthier people and better long lives and all that. We’d get wildly lower costs to our study in the PITAC showed about 70 or 80 billion dollars a year. But the Institute of Medicine came along and did the big study and came to 700 billion dollars a year of savings for the country. And we get an entirely new kind of science. But other than that, it’s, you know, it’s probably not worth doing. So, we’re all married to this, right. And we now have computers everywhere. But there is pain. Everybody hates them. That’s largely because we haven’t had this sharing in the internet part that makes that work. So meaningful use came along we checked our 25, 15 or 20 or 10 or 16 boxes and got our checks. And now it’s switched to PI, promoting interoperability. And the PI penalties are real. Two of the six criteria are called referral loops or HIE measures or, you know, getting your care coordination going. They explicitly require getting of facts for a large proportion of referrals and discharge and transitions of care out of your own organization, 40 of the 50 points you need for PI and that’s 2 percent or 3 percent of your hospital payments from Medicare. So that, you know, for a medium or a bigger hospital, that’s 5, 10, 15 million bucks a penalty. So, there’s real meat now behind some of those and those the screws are tightening a little bit on that arena. And so, there’s some value there. We see the biggest value for getting this working, you know, the two thirds or three quarters or whatever it is of doctors and clinics that don’t work for you in a hospital. We really need to coordinate with these guys. In the past, we’ve ignored the people on the other side. But now that we’ve fixed the inside and it’s possible to do all the basics in the hospital, now it’s time to sort of extend. I hear this all the time from the CIOs. We’ve spent the last five years making this work at all. Now if we can only get the outside provider’s data and get them engaged and make it so that their job is easier and maybe make it so that they get some PI benefit or efficiency benefit, we’re still spending a huge amount of our time on the telephone and waiting around for the other doctor to talk to the other doctor or hiring a massive care coordinators to call and to show up at eight o’clock every morning and dial for dollars. And this is all nuts. This is 20 years ago. The internet fixed that for other industries. And it’s easy enough to find the efficiency value of tightening up your referral network and getting above 50, 60 percent referral leakage. And, you know 2, 3, 5 percent improvements in referral leakage add up to many millions of dollars of new revenues for a hospital.

Paddy Padmanabhan: Yeah, it’s very interesting. You mentioned banking and you mentioned how other industries are much further ahead. And John Glaser, who is the former CIO of Partners Healthcare, who is on my board of advisors, he wrote an article about this in the Harvard Business Review, where he pointed to this exact same contrast between banking and healthcare. And he makes the argument that you don’t have to do the whole hog, do everything the banking has done. But even if you do it selectively and move the needle, their significant gains to be had. And one of my other guests on the podcast, Daniel Barchi, who is the CIO of NewYork-Presbyterian, he made a very telling comment, he said we have really low thresholds today for digital engagement in healthcare. If somebody uses an online platform just to schedule an appointment that counts as digital engagement and that counts towards digital-enablement patients, and it can qualify you PO points for all kinds of incentives or conversely, penalties as the case may be. Healthcare I think is very unique in that regard because it is a system of incentives and penalties that are driving in many ways digital adoption. Is that a fair statement?

Peter Tippett: Yeah, I think so. You know, I think that the regulators have the right end game in mind. And I think that the knobs are roughly aligned and reasonably aligned. But nobody no business aligns themselves around regulatory incentives unless it’s also valuable to the business. I’ve had I can’t tell you how many CIO discussions I’ve had where they said, why aren’t you worried about this three-million-dollar penalty? And the answer is, if I spend so much of my energy worrying about that I wouldn’t do my business. We have to solve our real problems inside the business. And if we can make it align with getting two or three or million dollars or 10 or whatever it is, the feds fine, right? But it can’t be the principal driver. And so, the argument in banking is they’ve got a simpler data set than we do in healthcare, and that’s true. But tearing things down to the simple issue, you know, meds, problems, allergies, and demographics get that actually working, make it actually digital and get it sharing in both directions and make it work easily, whether at the other end is using a browser or there’s hundreds of EMR as it might be when your brother in law invented and there are twelve other users in the country that you still have to make it work with whatever the other guy is using and getting down to the basics and making the communication work at a really basic level is the key. And you know, once the basics are working, it’s easy enough to extend those a little bit.

Paddy Padmanabhan: Yeah. So, we are at the close here Peter. I would just love to hear your thoughts on what you’re seeing, your customers and health systems, in general, investing in as it relates to digital transformation. What are the top two or three things that you think that you see them focused on?

Peter Tippett: Yeah, I think that as a community, the health systems and IT activities in hospitals and bigger health systems has gotten the inside job pretty well under control. They are feeling like they’ve got, you know, actual functional EMRs, EHRs that actually do the basics and people are being productive with them on the inside. And so, I think there is a view towards the outside. We call it different names of call care coordination, we call social determinants, we call it enabling, you know, the home health workers, all those. We get lots of different names for all this stuff. In the end, it’s very virtual health. It’s getting, you know, getting the communication working. In the case of B2B, getting it working among providers means that you don’t have to force the patient to carry the record or come get it or be the middleman. And everybody wants the patient to have the data and be able to deal with it. But none of us make it. It doesn’t make a lot of sense to force the patient to be the connectivity link. So, I think that we’re getting towards this place in our world where we are enabling the communications. These platforms like carequality and the national sharing platform they’re getting some traction. The vendor platforms by Epic and others, they’re getting good traction. They enable good pieces of what needs to happen. But they don’t enable two-way communication. They don’t enable messaging. They don’t often enable giant things like x rays, sharing or other pieces. They often don’t enable a little guy very well on the Oddball platform. And so, you know, providing the glue that sort of fills in the gaps between the stuff that does work seems to me to be the place to be. And I think the venture community and the venture incubators and hospitals and health systems and those kinds of groups, they’re really a powerhouse. They’re the ones that can get the little startup guys and the new innovation guys. They can keep them on track. They can give them the focus they need because all kinds of people have good ideas. But all of us inside, you know, we largely are scientists in this world and businesspeople and the venture world in an incubator, they’re supposed to be experienced. And the good ones do help focus on actually making the change happen.

Paddy Padmanabhan: That’s said. In fact, in my recent podcast, I had a couple of senior executives from Epic and kind pretty much said the same thing that you just said, at least in terms of their product, focus on their platform, focus in terms of facilitating the seamless exchange of information, if you will. Well, Peter it has been such a pleasure speaking. There’s a lot that we can talk about and hope to carry on with the conversation and have you back on our podcast sometime soon. In the meantime, I wish your company, careMESH, and your team all the very best and look forward to staying in touch.

Peter Tippett: Great. Thanks so much.

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. Peter Tippett is Founder and CEO of careMESH, former Chief Medical Officer of Verizon, and a leader in Health IT transformation, information security and regulatory compliance. Among other start-ups, Tippett created the first commercial anti-virus product, which became Norton, and founded TruSecure and CyberTrust. He was a member of the President’s Information Technology Advisory Committee (PITAC) under G.W. Bush and served with both the Clinton Health Matters and NIH Precision Medicine initiatives.

Tippett is a physician, board-certified in internal medicine, and was Research Assistant to R.B. Merrifield (Nobel Prize, 1984) and Stanford Moore (Nobel Prize, 1972) at Rockefeller University. He received a PhD in Biochemistry and an M.D., from Case Western Reserve University, and a B.S in Biology from Kalamazoo College.

Throughout his career, Tippett has been recognized with numerous awards and recognitions — including E&Y Entrepreneur of the Year, the U.S. Chamber of Commerce “Leadership in Health Care Award,” and was named one of the 25 most influential CTOs by InfoWorld.

About the host

Paddy is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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We essentially see ourselves as stewards helping clients manage their data

Episode #34

Podcast with Seth Hain, VP of R&D and Sean Bina, VP of Access and Patient Engagement, Epic

“We essentially see ourselves as stewards helping clients manage their data”

paddy Hosted by Paddy Padmanabhan

In this episode, Seth Hain, Vice President of R&D and Sean Bina, Vice President of Access and Patient Engagement at Epic discuss the next wave of opportunities for Epic and how the company has evolved by focusing on patient experience and advanced analytics.

At Epic, the focus has always been on providing patients with access and tools to view and have control over their data. Epic works with over 300 health systems today to help them manage their data. Over 160 million consumers have or are using its MyChart patient portal which has been around for nearly two decades. The company uses advanced analytics such as AI/ machine learning and monitors how they are performing on different populations before embedding it into workflows, be it clinical-facing or patient-facing.

Epic has lately started focusing on providing transparency around healthcare costs and has been working on creating accurate estimates for patients so that they have price transparency at the point of care.

Welcome to The Big Unlock podcast where we discuss data analytics and emerging technologies in healthcare. Here are some of the most innovative thinkers in healthcare information technology talk about the digital transformation of healthcare and how they are driving change in their organizations.

Paddy Padmanabhan: Hello again, everyone and welcome back to my podcast. This is Paddy and it is my great privilege and honor today to introduce my special guests. We have two of them today, Sean Bina, who is a Vice President for Patient Experience with Epic and Seth Hain, who is VP of R&D for Epic. Seth and Sean, thank you so much for joining us and welcome to the show.

Sean Bina: Thanks for having us.

Seth Hain: Thank you.

Paddy Padmanabhan: You are most welcome. So why don’t we get started? Maybe you can give us a little bit about your background and your current roles at Epic for the benefit of our audience.

Sean Bina: Yeah, so I’ll start. So, this is Sean and I started at Epic 23 years ago doing implementations of our systems. And then over the years, I’ve worked with a variety of our different products and now focus my time on the patient experience. And that’s really my goal, to help patients get connected into their health and wellness in a way that they’ve never been able to before.

Seth Hain: My name is Seth and I started a little after Sean. I’ve been here for about 15 years and when I came to Epic, my focus was on architecture and the kind of systems infrastructure behind the scenes. And then I combined that with my prior experiences around mathematics and focused on and continued to today the research and development around analytics and machine learning and in particular embedding that type of intelligence into workflows, be it clinical facing or patient-facing, for example. And the tools that are used throughout the system for analytics and machine learning.

Paddy Padmanabhan: And between the two of you, I would argue that you are looking after the top two focus areas for health systems today – patient experience and advanced analytics. So, I’m looking forward to this conversation. I want to start with this, now we have near-total penetration of electronic health record systems in the country today. Of course, it’s been a great run for Epic as leaders in the market. So, what are you seeing as the next wave of growth opportunities for Epic?

Sean Bina: So, we see a few different areas where we’re continuing to do a lot of work. One is we just continue to work with our customers to expand the adoption of Epic and then to add new additional modules. One of the things that we’ve learned over time is that every specialist needs a system that’s really designed specifically for them, whether they are core things that all physicians and clinicians use around ordering and reviewing results and doing some basic documentation. But then there’s a lot of subspecialty support that’s needed for doing things like managing images, for registry support and for doing the kind of specific documentation within a given subject area. So, we continue to go deeper and deeper into those areas to create a great experience for physicians. The one thing I would add is when we look at the industry in general, we do see our customers are really focused on three core areas. One being patient experience, two being analytics, but then three is really bringing the joy back to practice for physicians.

Seth Hain: I would also add that the space around healthcare continues to change and evolve. And I think there’s a lot of opportunities as we start to look at and see more collaboration between, say, payers and providers in the space. There is an opportunity there to help facilitate faster exchange that benefit both the provider and their workflow, but also the patient and the care they’re receiving in a timely manner. And that expands as you start to think about a broader definition of health. Thinking about things like dental, long term care, even where people get care, be it a telehealth encounter through, you know, they pay from the app directly on their phone, or they’re in a retail clinic and they just need to swing by for a flu shot and making sure that’s a continuous experience from a health perspective.

Sean Bina: The other thing that we continue to work on is we continue to move internationally. So, you know, outside the U.S., we work with an increasing number of countries on our software and there’s kind of a wonderful cross-pollination that we get as a result of that. So, for example, we’ve been working a lot with Finland and they’re very focused on social determinants of care, really, really focused on reducing the need to get into the hospital or readmissions into the hospital. And so, a lot of the work that we’re doing with them around their social care system then ends up benefiting our U.S. customers.

Paddy Padmanabhan: Right. Right. And we’ll unpack some of these, especially around the emerging tech stuff in the context of digital transformation, which is what we mostly focus on as a part of this podcast. So, let me ask you a simple question. What is your understanding of the term digital used by everyone? And almost everyone has a definition for it. And how do you define digital? What is your understanding of the term and how is it impacting all your choices or investments in health systems, specifically from your point of view with your clients?

Sean Bina: Yeah. If you don’t mind, we take a quick trip back down memory lane. You know, when I started back around 20 plus years ago, the world was very different in terms of what was available from a digital perspective. You know, there weren’t integrated ambulatory inpatients solutions. You couldn’t do an end to end revenue cycle system that covered all your hospital and clinics. And so, people were using best of breed systems and trying to cobble systems together to manage all of that. And until around 2003, there wasn’t even such a thing as a patient portal. So, one of the things that when I think about what it means to be digital today, it’s obviously changed over the years. But I think it’s important to remember how far we’ve come that we now do have fully integrated systems that cover all the kind of food, warmth, and shelter that is needed by healthcare organizations. So that now we’re getting to the point where we can do a little bit more of the poetry.

Seth Hain: I think that depending on who you ask or the definition of digital transformation, you tend to hear a pretty different perspective. Some people immediately come at it from the patient experience perspective and the possibility of having access to health care through your phone at any point in time. Others and I tend to take a foundational view of systems perspective on some of these topics. You know, start to also bring in things like cloud computing behind the scenes and the running of machine learning algorithms on data that is flowing into the system from a combination of devices. Then being able to be back into wherever the provider might be so that they can be sure that in the ICU, be that walking down the hallway so that they have a better-informed picture of what patients they might want to spend some time with at that exact moment in time. So, I think that gets to more of the transformation point in building on what Sean was saying.

Sean Bina: Yes one other key element of digital is the interoperability piece. So, if you go back to the year 2005, 2006, 2007, interoperability was a fax machine. We’re now passing five million records a day around the country and it’s starting to be around the world for patients. And so we’re really starting to see where physicians have gone from thinking of records from the standpoint that I have my record at this site versus there are other records at other sites to wanting to have combined digital views of all of a patient’s information pulled seamlessly together.

Paddy Padmanabhan: Yeah, I think we certainly have seen a significant amount of progress on interoperability. But I just wanted to make one observation. You know, when you look at the past decade or so, well, the single biggest thing that happened in terms of digital transformation was really the digitization of medical records. I remember working with paper records with my physician 10 years ago, and it so happened that he was fighting tooth and nail about going digital. But if you really look at it, I don’t think any of the sectors has seen the kind of transformation that healthcare, in particular, has seen, just by virtue of digitization of medical records. So now it looks like we’re, you know, phase one of the mission has been accomplished. Now they have the strong foundation of digital records. And so, everyone seems to be talking about what do we do next with it? Advanced analytics, building better experiences, looking at data from multiple sources and so on. So, in that context, the whole competitive landscape is also changing. So I want to probe a little bit on how you see Epic evolving in the context of this emerging landscape of technology players and the evolving needs for health systems, as they compete with a whole different marketplace with a lot of nontraditional competitors in all kinds of other things going on. Do you want to comment on that? How are you evolving and what are the changes you’re seeing your clients go through and how are you evolving in step with that?

Seth Hain: You’re getting back to that kind of world of transforming from a paper chart to a kind of maybe a desktop PC where somebody would go to get information, I think is an interesting analogy to kind of transformation we’re seeing right now where in many cases it’s not about the chart, right? It’s about a continuous health experience that folks are receiving. Be that a patient or a provider. So, we see somebody like Rush down in Chicago who builds automated workflow to understand as patients come into the E.D., their likelihood to leave based on machine learning algorithm using inputs from a variety of different sources, not just the medical record, and then use that to help drive workflows where they can walk around, touch base with the patient, let them know where they’re at from in my perspective, to see a nurse or a clinician. And they saw a drop of about 50 percent in folks leaving without having been seen from the emergency department. So, you start to see a different type of transformational workflow emerge that isn’t based around a single machine but is more driven by a backend kind of ubiquitousness of data accessibility from a cloud perspective. And then differing devices be those iPads being used for rounding or watches used to alert physicians in the ICU of patients that might be at risk of deterioration from based on a machine learning model. So, it really starts to transform how clinical practice is being given some of the financial aspects as well, are also are being looked at.

Sean Bina: Yeah, I would just add from the patient perspective, I think they don’t think in the same way as they used to that I have a record at a particular healthcare organization. Increasingly, they’re thinking about their health and wellness and how that includes what’s going on their Fitbit, and on their Peloton and on the medications that they’re taking. And so, they’re looking at a much broader ecosystem of inputs. And I think the expectation is growing that what healthcare organizations are going to be able to do is take all of those inputs, pull them all together, and then provide recommendations based on a much broader set of data than that’s ever been data available in the past.

Paddy Padmanabhan: Yeah. And my firm did some research back in the summer of 2019. On the current state of digital transformation in healthcare, and what we found was that over half of the health systems that we polled in the study were looking at the electronic health record platforms systems as a starting point for the digital transformation. One of the reasons was that integration aspects in pulling data adding it all from within the workflow of an EHR system is easier to do. And when you talk about digital transformation, people are talking about integrating data from multiple sources. But it’s still a lot of integration work that is involved here. I want to switch at this point to talk about the data itself. You know, your obvious strength for Epic is in the data that you have access to, all the patient records that are being processed through your system, across all these health systems across the country. Now, that is a huge advantage to Epic as you try to build out your models and as you try to build out your experiences and just get a better understanding of your patient populations. Can you share a couple of examples of how you’re actually using the access to the data to improve experiences as well as outcomes for patients? Do you want to talk about one or two examples? Maybe you mention a couple of clients where you’re doing some work in this regard?

Seth Hain: Yes, sure. So, I can address a couple of those points. One of the things to be clear here about is that organizations work with us and we essentially see ourselves as kind of stewards helping them manage the data that they have on-site. And we work with them to kind of build out workflows that have the opportunity to be fully informed by the data in their system and the context around the patient and the provider. We often think of this internally as a concept we call relevance, where we want to make sure that full picture is brought to bear. I mean, some of the easiest examples to think about in this context are around the acute space where we rapidly see folks deploying machine learning models around things like sepsis, deterioration, and fall risk being three of the most common ones. We see folks start with often implementing them as a bundle. And at this point, we have over 300 organizations either running directly in their system or in the midst of implementing machine learning models in those types of contexts. And it’s exciting to see the impact that it has. And, you know, it ranges from something like a 17.7% decrease at the North Oak, which is a community hospital down in Louisiana in mortality reduction for sepsis patients to, you know, also a decrease in alerts that providers are saying you use machine learning models to better identify patients. It also helps save folks time. So, UC Health, who spoke to Amy about this, saw a 19 percent reduction in the number of alerts they were seeing in these types of contexts as well. So, it both benefits from a provider time saving perspective while improving care.

Sean Bina: We also do models on the operational side of the house. So, doing things like identifying the patients that are most likely to “no show.” So, in the past, you obviously could run kind of massive report and you could do a lot of analysis and trying to find this information. But now we can’t just have the system waiting. What are the most important variables and identify which patients are the most likely no shows and then do things automatically based on that information? So, whether it’s doing a reminder phone call or texting the patient or whether it’s overbooking the patient because they’re unlikely to show up at a particular day in time. We can automate some of those processes. For me, that’s part of the excitement as you mentioned, as we’ve got completed the underlying digital transformation; we can now do these things. One of my favorite examples is what we call a FastPass at Epic, what it does is it automatically monitors the waitlist, identify the patients that are at the highest risk and need to get in the soonest, and then will automatically text or email them when new appointments become available. John Hopkins, they saw about a twenty-seven-day improvement from when patients were scheduled with a specialist until when they got in based on using this FastPass. So at one time improves the convenience and access for patients, but then at the same time, it also helps the healthcare organization because you’re filling times that would have otherwise gone unfilled or where you would have had to have a lot of staff managing the situation.

Seth Hain: And to your point, Paddy, I think, about platform, that equally important to data in regards to machine learning and these types of scenarios is the workflow in understanding what data is present and ready to be used at the point in time that somebody can make an intervention that will really matter and how to get that information into the people’s hands. They can do something with it. And so, as we build out more machine learning models here in the data science team at Epic, that’s actually where we start. It’s not with the data that’s available or those sorts of things, but it’s about the impact that we want to have in the workflow and how we see that fitting in and then work back towards the true kind of machine learning training processes and the stuff that the data scientists really do day to today.

Paddy Padmanabhan: Yeah, there was this one question that I have on this. When I talk to CIOs and digital transformation leaders, one thing that I hear often is that it’s very important to identify the right kind of use cases if you will, or AI II and machine learning applications. And often I’ve heard that the bigger opportunities today, maybe in more in non-clinical use cases, administrative functions, and revenue cycle management as an example or even for the patient experience related applications. Is that the sense you get in based on all of the work that you’re doing that we’re further ahead? Or maybe there’s a bigger opportunity in the short term with non-clinical versus clinical use cases? What would you have to say on that?

Seth Hain: I would hesitate to say that that is exactly what we see. I think it’s different depending on the area. Certainly, in the operational areas, we see real opportunities for automation, and we see folks using machine learning embedded into the workflow to save folks time and energy in regards to moving through those operational workflows. On the acute side, we see a variety of impactful outcomes like the ones I just referenced, be it around deterioration, be it around sepsis, be it around palliative care. There is a lot of opportunity that folks see there and documented outcomes such as on the North Oaks, one that I shared a moment ago. There is also real opportunity in the population health space. I think it is harder there to truly measure the outcomes when you’re looking out two to three years in regard to the impact that folks have and directly tying it to the clinical management and care management that takes place. That’s not to say that it doesn’t help. You know, we have documented evidence and dug in as we build machine learning models around, say, sorting outreach for diabetic patients just based on an A1 C value compared to a predictive model of their two-year risk of Type 2 diabetes complications. We can really see a difference in the math when we dig into that. It’s harder and takes longer to produce those studies, though, about outcomes longer term.

Paddy Padmanabhan: Yeah, yeah. But let’s switch to the patient experience. Patient access, patient experience, these are hot topics for health systems today, high focus areas. And there’s also a teaming ecosystem of a digital health startup funded by billions and billions in venture capital money that are addressing specifically the patient experience and patient access aspects of the healthcare value chain. Now, you know, when I look at health systems, I ask myself – what would we be looking beyond an electronic health record system for? As I mentioned earlier that half of the health systems that we polled in our study were already using electronic health records systems for most of their digital functionalities. But there is also a growing trend of using startups. So, I guess this is a question for Sean. Where do you see Epic fitting in this overall milieu of digital startups that are coming up with maybe new ways of defining experiences and new solutions? Where do you see Epic fitting in this overall context?

Sean Bina: Yes. So, first of all, a little bit of context. MyChart has been around for a long time now. It goes all the way back to 2003 when we first went live with it. And kind of the patient side has always been a focus for us at Epic in terms of providing patients with access and tools to be able to see and view their records. That’s always been a core thing that we want to make as seamless as possible. And we now have almost I think we’re over one hundred and sixty million MyChart accounts. So, we’re closing into the point where about one in two people in the country having and are using a MyChart account today. And we’re starting to see much greater adoption than in the past. So, I think in the past, you know, we would see our customers have around a quarter to a third of their patients be active MyChart users. But the trend is way up. And so, for example, one of the most interesting things I’ve heard recently is that at M.D. Anderson, if a patient is seen three times, then there’s a 90 percent chance that they’re using MyChart for M.D. Anderson. Now, of course, those are patients that are sick, and they have a whole set of issues. But what it shows is that patients really will adopt the technology when it comes to using it, when they do have health issues. And so, I think one of the questions for us is not will patients use MyChart if they’re sick and they have chronic diseases and they’re in for surgeries and all of that. We know that for patients that are connected to health systems, that they will become active adopters of MyChart. But for people that are generally well or have particular health concerns are just trying to manage their health issues, but are not constantly going in to see the doctor, how do we reach out and get connected to those patients? And so, our focus is really kind of turning to help patients do a lot more self-management and do a lot more wellness within the system than we’ve ever done in the past. Some of that is providing people with targeted education based on the information that’s flowing into Epic. So, when you talk about this whole ecosystem of startups, a lot of startups feed information in which we can then consume and take advantage of in Epic. So, whether it’s your blood pressure monitor, your heart rate monitor, whether it’s your Fitbit, whether it’s your Apple Watch, all of those things then become data feeders that then get, consumed through MyChart up into the EHR and then we can provide monitoring and management of that data based on configuration within Epic.

Paddy Padmanabhan: Yeah. And you know, one of my recent guests on the podcast mention that right now we have a fairly low threshold for option of digital tools by patients. If people start using the tool, that itself is a significant change. And it’s really heartening to hear that you’ve got 160 million patients who are now beginning to actively use MyChart in some way. I am one of them, by the way, and I can’t remember the last time I actually called into my physician’s office for scheduling an appointment or just for non-emergency type questions. I do that all through MyChart today.

Sean Bina: Yes. I’m the same way and I use MyChart all the time for managing my daughter’s care and then managing my care. And so, you know, I love to access digital tools and I would much prefer to always do something online than have to make a telephone call. And I think many, many patients are in that same boat. There is a cultural change that still needs to happen at many health care organizations to give patients more control. So, one of the things that I’m continually advocating is that we don’t need to wait to give patients their test results until after a physician has reviewed them. We should be providing open notes to patients as much as possible. And so, we have those capabilities within MyChart today. And so, it’s just a matter of transforming the healthcare system. And some of this will almost certainly be mandated by the government in the next year or two is that really to provide that full context for patients when they go into their shared medical record.

Paddy Padmanabhan: Yeah and that would be a huge leap, actually, especially the comment you made about the notes and all that. So, let’s talk about emerging tech stuff again. You know, we talk mostly about digital transformation and now we are on the cusp of some big breakthroughs with some of the emerging technologies that can potentially play a big role in the way health care is delivered in the future. So, we just touch on a few of them. And let’s start with this one, cloud computing. What are your thoughts on the role of cloud going forward in digital health?

Seth Hain: I think there’s a number of things that cloud computing provides, but at the end of the day, I think it is really about faster delivery of technology to folks to be able to put it into practice. So, a couple of years ago we released our cloud-based machine learning platform, which is essentially provided as a service and allows organizations to embed directly into their workflows, machine learning algorithms that run in real-time on the latest data in the chart. And when we built that out, we build it out in a manner that used. Forgive me, I’ll dive into a little bit of techno-jargon here, but used containers, which is a kind of new approach for deploying software out on the cloud and is agnostic, so that runs on Microsoft Azure today can run on other platforms as well in the future. And that enables organizations to also both getting access to new things we’re developing here in Verona, but also to embed their own software more efficiently. So, we’ve seen organizations like Ochsner who now have deployed nine different machine learning models directly onto that platform and embedded them back into their workflows. So, they see this as a tool to allow them to more rapidly evolve both their clinical and financial operational workflows. And they share those types of results and approaches our UGM conference, XGM, and in other forums so that folks can learn how to do that and move more quickly with it. So, I really see cloud as an approach for faster delivery and that then enables that type of faster execution on new clinical programs and the like.

Paddy Padmanabhan: Yeah, I had a quick follow up question on that. So you mentioned Microsoft Azure, so they are the big tech firms that have their own plans for the healthcare market, in some ways they may well be competing with you, and in other ways, you could be partnering with them. So how do you approach this today at Epic? Where are you partnering with? What do you think you’re going to be competing and what do you see as it relates specifically to the big tech? I’m talking Microsoft, Google, Amazon in particular.

Sean Bina: Its really customer driven. So, you know, its what customers are coming to us and asking us for and then us doing an evaluation on our side in terms of what models are going to work the best, who’s the best groups to partner with?

Paddy Padmanabhan: Right. OK, good. So, let’s move on to the next one on my list – voice recognition. Boy, I have to tell you, I’m pretty excited about what I see in terms of its potential. I just saw a news item that said that we now have the ability to identify biomarkers based on voice. And I thought that the future of health is here. But anyway, I don’t want to get too far ahead of myself. What do you guys think?

Sean Bina: Oh, we’re super excited about voice too. So, you know, people have been using voice obviously for years in terms of using systems like drag and then model to capture notes. And we have a lot of physicians that are highly efficient doing that. But we certainly want to kind of add a few additional layers onto them. And so, the first thing that we did was we started creating a voice assistant. We now have a voice assistant that runs on our mobile platform where I can say, hey Epic, and then have it answer certain sorts of questions for me. And then we are doing the work to move that into hyperspace. So on the workstation, you’ll be able to have a microphone where it will work in the ambient fashion and you’ll be able to use voice commands to drive workflow, to find out information about a patient, and to really work hands-free. I think a lot of our focus is, you know, where does this technology make sense? Whether it’s, you know, in the room for an inpatient where the patient is the driver, whether it’s in the OR, where people are scrubbed in or whether it’s in the clinic where the physician is focused on the patient instead of being focused on the workstation. And how can they quickly get the information that’s most relevant and then get things cued up in a simple and easy fashion? And we feel like the voice assistant is going to be a great way to do that. And then a little bit farther, but not that much farther down the path is the conversational capture with diarization and natural language understanding to basically be able to start to construct a note out of the natural conversation that is happening during a visit. We’re already seeing kind of experimental groups are doing this in areas like orthopedics where you have pretty structured common visits that are happening over and over again and then using machine learning to eventually get to the point where instead of having a human being as your virtual scribe, the system is really the virtual scribe creating that note.

Paddy Padmanabhan: Yeah, ambient clinical computing environment I think that’s kind of becoming a term in vogue today. I saw one of my earlier guests on his podcast mention that in 10 years’ time we’re going to completely keyboard-less and we’re going to have a voice-enabled or ambient computing environment where you don’t need a keyboard anymore. That’s where physicians are looking forward to that because that is going to significantly reduce their burden. But, how close or how far away are we? Is voice recognition mature enough today? What are the error rates within control, what’s your quick comment on that?

Sean Bina: Kind of we’re learning a lot right now is what I would say. So, we know that voice recognition works when I have a microphone in my hand and that they are at 95, 96, 97 percent accuracy using the new cloud computing platforms. So, for example, when Dragon moved to the cloud, the accuracy increased, and it can handle more accents and different styles of speaking better than ever before. So, we know that the accuracy is really good in kind of that clinical scenario. We’re kind of in the first layer of watching how the voice commands are being used and that hit rates and success for that. And we’ll learn a lot as more and more customers go-live. And then, you know, we’re kind of doing close monitoring on these first areas where people are piloting ambient voice assistance in specialty areas like orthopedics. So my sense is that in areas where you have a fairly structured dialog, you’ll have fairly fast adoption over the next year to two years in areas where a kind of a more classic internal medicine visit, where a patient might have nine different problems and you have a 45-minute visit where you’re covering all different types of things with the patient and doing a lot of education. But that’ll take a little bit longer.

Paddy Padmanabhan: Yeah. Yeah. Well, I’m still trying to get my car to listen to me and play the exact song that I want to hear. And so, I am, I guess, a little further away on this. So, the last one on my list for emerging tech and we’ve covered a fair bit of this with Seth as far as, you know, artificial intelligence. But I do want to touch on one thing as it relates to that topic. I hear a lot from people who are practitioners in the field and the customers as well that there are some concerns, they have about black-box algorithms, algorithmic bias, even some ethical considerations around the use of AI in certain contexts. So, Seth, do you have any thoughts on how we address these and where we are in really gaining or enabling customers and users to gain more confidence in these tools?

Seth Hain: Two things really, I think come to mind. The first one is really understanding how they’re being put into practice, where machine learning is really embedded into this system to kind of augment the information available to a user. I have a quote here from a user group meeting presentations from Denver Health, where they were talking about implementing a deterioration index model and a nurse shared with the folks, then put it in the plot practice that the deterioration index doesn’t change the way I nurse my patients, but it gets me into the right rooms faster. Right. So, understanding how those are embedded into the workflows I mentioned previously, I think can certainly go a long way to addressing it. The second piece that comes to mind is really about the process that an organization goes through as they implement I and put models into practice. First, understanding how it is performed on similar populations. What went into building the models? We published briefs on every model we create that organizations can review prior to putting it into their system. The second is the ability to run that model silently and understand how it performs at the organization in the context that is likely to be used in prior to putting it into practice. The third is obviously putting it into the workflow and making sure that users understand the context in which is being included and having it embedded directly there in an explainable fashion.

Sean Bina: And actually, this is true not only for AI/ machine learning, this is true for all decision support. You can’t turn on the decision support alert without first running it silently seeing when it’s going to be triggered. How often it is going to be triggered and whether it’s being triggered in the right circumstances? And then you have to measure over time how a decision support alert is being used for it to be effective.

Seth Hain: And I think that last point is key here. It is often not talked about in the context of machine learning, where after you have machine learning models live and in practice, it’s important to continue to monitor them and understand how they’re performing on different populations and then taking steps to adjust that where appropriate. It might mean adjusting the model. It might mean adjusting the workflow. But understanding its performance on a variety of different individuals, and in a variety of different circumstances over time is key and we provide that type of monitoring capability directly within the platform for augmentation.

Paddy Padmanabhan: Yeah, I think that makes a lot of sense. We’re coming up to the close for our podcast here. Is there anything that you’d like to share with our listeners about any new product features or new functionalities that you planning to launch this quarter or the next quarter?

Sean Bina: One thing that has been available for a while that I would just quickly highlight because we didn’t talk about it. We didn’t talk very much about the financial side of the house. But transparency around how much healthcare costs is absolutely essential. We have to make it so that as patients are coming in for their visits, they have a good sense of what this visit or procedure is going to cost them, what’s going to be out-of-pocket, what’s going to be covered by their insurance, and provide them with an understanding of the mechanics of that. In many cases, a patient might even be charged differently going to the same healthcare organization, depending on whether they’re going to the clinic or the hospital for the same disease. So, we have to make sure that patients know about that as they’re making these decisions about when and where to go in and who they’re going to be seen by. And so, we’ve been really focused on being able to create estimates for patients that are highly accurate based on historical data and can be provided at the point of care by the doctor. So, the doctor can say this is what an upper GI is going to cost. He or she can say what the medications are going to cost and whether there are less expensive alternatives. And then also providing that same information as a patient is going in to schedule their visits and procedures. So, to me, that’s a really big deal and it’s something that could really transform a patient’s experience by not being surprised by what the costs of things are in the end.

Paddy Padmanabhan: Yeah. And I agree completely with you. It is a big deal. I think the price transparency, cost transparency is something that is unfinished business as far as healthcare is concerned. Well, Seth and Sean, it’s been such a pleasure speaking with both of you. I greatly appreciate your joining us on this podcast. And I look forward to catching up with you again soon. Thank you again.

Sean Bina: Thank you.

Seth Hain: Take care.

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

Rubik Cubes make a perfect gift for any occasion. Learn more about this entertaining puzzle visiting ruwix.com.

About our guests

Seth Hain, Vice President of R&D at Epic, focuses on integrating analytics and machine learning into healthcare. This includes the development of business intelligence tools, data warehousing software, and a platform for embedding machine learning across Epic applications. During his 13 years at Epic, Seth has also led the Systems and Performance group, with an emphasis in database performance and architecture.

A native of Seward, Nebraska, he received a BS in Mathematics from the University of Nebraska and an MS in Mathematics from the University of Wisconsin. Seth currently resides in Madison, Wisconsin with his wife and two children.

Sean Bina is the Vice President of Access and Patient Engagement at Epic. His focus is on improving health and wellness by helping people to become more connected, knowledgeable, and in control of their care. He currently divides his time between strategic application planning and product management. During his 23 years at Epic, Sean has worked as an account manager, team leader, implementer, an RFP writer, and as a salesperson.

Sean graduated from Beloit College with a degree in Philosophy and Literary Studies. He lives with his wife, daughter, and dog in Madison, Wisconsin.

About the host

Paddy is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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Digital medicine is just medicine

Episode #33

Podcast with Daniel Barchi, SVP and CEO, NewYork-Presbyterian

"Digital medicine is just medicine"

paddy Hosted by Paddy Padmanabhan

In this episode, Daniel Barchi discusses the current state of digital transformation in healthcare, their goal to bring cutting-edge technology, and focus on delivering outstanding patient care.

According to Daniel, a good technology is one that saves clinicians and caregivers time without getting in their way. He believes that healthcare technology is “80% people, 15% process, and 5% technology.” He further cautions that while using advanced technologies such as AI, health systems need to be thoughtful, careful, and respectful of the way technology interacts with patients.

The healthcare system as a whole has very low thresholds for measuring progress in adoption rates for digital health tools such as digital front doors. Digital health startups have a lot of brilliant ideas; however, they are years away from being integrated into core EHR systems. Daniel advices startups to get deeply embedded with their clinical partners to develop innovative solutions for healthcare.

Welcome to The Big Unlock podcast where we discuss data analytics and emerging technologies in healthcare. Here are some of the most innovative thinkers in healthcare information technology talk about the digital transformation of healthcare and how they are driving change in their organizations.

Paddy Padmanabhan: 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, Daniel Barchi, CIO of the NewYork-Presbyterian Hospital. Daniel, thank you for joining us and welcome to the show.

Daniel Barchi: Great. Thank you for having me Paddy.

Paddy Padmanabhan: You’re welcome. So, Daniel, I was at your presentation recently at the CHIME Falls Forum and your presentation was titled ‘Digital Medicine is just Medicine.’ We know that healthcare is in the early stages of a digital transformation. So maybe you could start by giving us an assessment of the current state of digital transformation in the healthcare sector.

Daniel Barchi: Sure. Well, thank you. First of all, I’d think I’d start by saying digital medicine is just medicine in the same way that really good technology is not about technology. It blends into the fabric of what we do in our everyday lives. So, at one point, I’m sure it was novel that somebody owned an automobile and today we don’t think about owning or using an automobile. I was reading the book ‘Thinking Machines’ recently about the birth and growth of artificial intelligence. And it pointed out the fact that the first supercomputers were huge, and they filled rooms and now they’re small and, on our wrists, and we just don’t think about technology. And in the same way, technology and healthcare is important. Quite frankly, if we’re eating up physician or nurse time dealing with technology, then technology is not doing what he or she needs. The technology that’s important for medicine called digital medicine is that which blends seamlessly into what we do daily in taking care of our patients. And so, it’s my goal and that of my team to certainly being on the cutting edge of what technology can offer. But it’s not an end to itself. It just blends into our larger focus on delivering outstanding patient care.

Paddy Padmanabhan: Right. And I recall you had mentioned something along the lines of technologies, 80 percent people’s, 15 percent process, and 5 percent technology. Did I get that right?

Daniel Barchi: That’s true. Although, you know, I’ve been using this quote for years and it was originally coined by my colleague, Marc Probst, CIO of Intermountain. And I use it all the time because it’s absolutely true. I’ll repeat it again. Healthcare technology is 80 percent people, 15 percent process, and only 5 percent technology. Day in and day out people who are leading technology transformation in healthcare are not focused on python programming, or XML, or interfaces, or FHIR. What we’re focused on is how does this work for the end-user? What do they need? Do they need the two of them? Or can we get down to one of them? Can we cut down the time that they spend digging around these systems by making it more ubiquitous? It’s all about the people on the process side, not the technology side.

Paddy Padmanabhan: Right. My firm’s research suggests that health systems are driving a lot of digital transformation initiatives. However, they seem to be a portfolio of standalone projects and for the most part, if I look at the health system landscape as a whole, most health systems are relying primarily on their electronic health record platforms for driving digital initiatives. Is this consistent with what you’re seeing in the market? And maybe you can talk a little bit about how you’re approaching it at NYP?

Daniel Barchi: You make a very good point. We always strive to adopt technology, which is going to be cutting edge and it’s going to help our physicians. At the same time, we want to make sure that it’s not getting in their way. And so, there’s a push-pull, the push being that we want to embrace small companies that are coming up with new ideas. And then pull being to make sure it’s part of the overall fabric of what we’re doing. And so, it’s a fine balance between being on the bleeding edge of what’s happening and being on the trailing edge of what’s happening. So, we like to think that we at Presbyterian were thinking about that balance from the physician and nurse’s point of view all of the time. We’re really focused on our core electronic medical record. And let’s be honest, that’s where our clinicians spend the bulk of their day. And we want everything to be accessible through the electronic medical record. We don’t want to say, sure, you do your core data and your core documentation and ordering in the electronic medical record. But when you want to use a cool decision support tool, log out and log into this other system, or when you want to use the latest PACS system, log out of the EMR and log into this other system. And so, you know, the great technology that comes in startups that are being innovative is generally years away from being well integrated into the core EMR. So, we need to think about where we can embrace the best of what’s cutting edge and coming from small companies, small startups, small standalone tools versus what we can incorporate in the larger EMR. And there’s probably a threshold, you know, something that is a 100 percent great idea, a standalone application versus 70 percent as good using the functionality of the EMR. Probably the 70 percent embedded in the EMR beats the 100 percent standalone because of the ease of working and for the idea that everything that’s done in the core system is interfaced with everybody else. So, it benefits not only the clinician who’s using that tool, be it the outside tool or the inside tool, but the inside tool is integrated into the seamless care of patients end to end.

Paddy Padmanabhan: Yeah, and this is very consistent with what I hear from other CIOs, as well as. This constant trade-off between what might be the absolute best in class on the one hand, but also what is more practical and optimal for the here and now. And you made a couple of very good points about the importance of not adding to the physician burden, which was kind of your underlying message about using the electronic medical record as the landing page or a landing point for physicians to use some of the advanced functionalities. Let’s talk about the front end a little bit. There is a lot of talk about digital front doors today and primarily relating to patient access. And a lot of health systems have launched some very intuitive apps, including NewYork-Presbyterian. And there are also nontraditional players like Walgreens getting into this space. What are your thoughts on how these digital front doors are reshaping the patient experience? And maybe you can share some thoughts from your own experience with the apps that you’ve launched, at NewYork-Presbyterian?

Daniel Barchi: Great. Thanks for bringing this up. Just to use an example, going back 20 years or more, we can think about a lot of this in the way that airlines did about booking and ticketing systems. In that 20 years ago, it was all about how the consumer, the traveler, gets in contact with the airline to start the process and make things happen. And today, it’s all about putting the perfect app in travelers’ hands and letting them make their reservations, do the special requests and drive the process. We can think about the healthcare industry being on the early phases of doing this, where certainly the clinical care is delivered by doctors and nurses in physician practices or in the hospital. But the coordination of it more and more is getting into the patient hands. And the only way you can allow them to do this if you give them access to the fundamental operating systems, primary through a portal. We’re going through the process of implementing a single common EMR across all 10 of our hospitals as well as Columbia doctors and Weill Cornell. Medicine is simply a huge endeavor, and as we think about this core EMR that we’re implementing, there will probably be about 45 to 50 thousand clinical and financial and operational users on a daily basis. But what we realized at one point is, you know, they’re probably going to be one hundred and fifty thousand patients that use this system every day through the portal. So, it’s great that we’re doing it for physician efficiency and for operations in the hospital. But it has to be a really good tool as a portal for the patients to use it and get the data themselves. And then I tie this back when I comment about standalone. Sure, it’s great if you’ve got a perfect fertility app or motherhood app or depression screening app, and it’s great that specialized standalone tool can go deep. But I think the best applications that face patients are the ones that go deep. But they’re also broad. They tie into the larger environment of care, including legacy records, including prescriptions and allergies and the ability to schedule follow up appointments.

Paddy Padmanabhan: Yeah, and can you talk to any metrics or how do you track the effectiveness of how these apps are truly reshaping the patient experience or impacting your own inflows if you will? What kind of metrics do you track for, telling whether it’s successful or not?

Daniel Barchi: Well, I will start by saying that I think that health care is generally still very new into this. Even core EMRs that have very good patient portals, it is the few and far between health systems that have really made great inroads in getting their patients to use them. And even when the functionality exists, getting the physicians and physician practices to use them and saying, you know, we probably don’t need Daniel at the front desk answering phones and making every single appointment for Dr. Jones, maybe we should open up Dr. Jones’s schedule. And I know that Dr. Jones is reluctant and that she really likes control over her schedule and understanding exactly what patients are getting scheduled when. But wouldn’t it be more efficient if we either had the front desk staff answering questions and doing follow up and not just making appointments and putting this capability in the hands of the end-user? So, I’d say that we as an industry are very, very new to this. And I think in many cases we’re testing the waters in terms of effectiveness. Most health systems, including us, are just measuring the percentage of our patients that are even signed up on the portal, never mind using it. It’s a very low threshold. So, what percentage of our active patients are using the portal today? The next step is going to get into, instead of process metrics like simply signing up but outcome metrics. So, we have more than nine million inbound phone calls to our health system annually. How do we reduce that over time by making a lot of what patients do online self-service? And we’re starting to adopt some artificial intelligence and putting it on the front end of our phone calls so that we can answer basic questions about scheduling or visiting hour time or directions, just very, very basic things to at least call off those basic things that can be best answered automatically for a patient. So that people who are answering calls are better suited to answer and more deeply the kind of question that our patients raised.

Paddy Padmanabhan: All right. I’ll come back to AI in a moment. But you mentioned health care outcomes in general. And of course, in the current era that we’re in. It’s all about data. It’s about harnessing data for insights. And it’s the number of data sources is increasing. The types of data is increasing. However, my understanding is that aggregating and analyzing the data in a healthcare context has been a challenge and remains a challenge despite some progress due to data quality, data silos, interoperability issues and so on. Can you share your experience at NewYork-Presbyterian on how you’ve approached this in your world?

Daniel Barchi: You raise a very good point. Data is certainly an outstanding tool to be able to improve our operations financially, from an efficiency point of view and from a clinical point of view. I often think that when people say it’s hard to get data out of systems, be it financial systems or billing systems or clinical systems, whether in healthcare or anywhere else. It’s sort of a lazy second hand for acknowledging that this work is challenging, doesn’t mean it’s impossible, but nothing’s easy. If you were to say, you know, organizing all the photos that my family has taken from all of our vacations and celebrations over the past 10 years. Yeah, that’s difficult. That’s not impossible. You need to do the work. I feel in the same way, aggregating and analyzing data is difficult, but not impossible. And where members of our research teams at Columbia and NewYork-Presbyterian and Weill Cornell have wanted to, they’ve gotten access to the data and been able to drill down and make real conclusions about efficiency or about clinical outcomes. And I think that it’s never going to be easily done until we get to national standard for how we record data in more discrete fields. We are always going to have issues of unstructured data, physician notes and the quality of the data and the quality of the data that comes from clinical care is never going to meet the standard that researchers want. And it’s our job as technology people who work in healthcare to tie the two together. But I wrap up again by making the point that just because it is challenging work doesn’t mean that it is impossible to do. And we should spend more time actually drilling down into what conclusions do we want to draw, what data sets we need to get that information from, and how do we go about taking the eight steps that are necessary to do it than simply saying it’s hard to get the data out of the system.

Paddy Padmanabhan: So, can you share a little bit of detail on what your data and data integration, data aggregation, and data management infrastructure looks like at NewYork-Presbyterian?

Daniel Barchi: Sure, we are doing a lot of good work led by our analytics leaders and informatics departments at Columbia, Weill Cornell and NYP to do two things, not only look at the data that we have on hand, but we’re planning the future because we are three institutions to top 10 Ivy League medical schools and a top 10 health system all working in concert. We have many, many different sources of data and teams using that data. And yet we’ve done a really nice job of having the leaders of these data sets and our analytics teams create shared governance. And in that way, we’ve been able to tie this shared governance to our new integrated electronic medical record and we’re looking for outcomes together. So, the analytic leaders from Columbia, Weill Cornell and NewYork-Presbyterian meet now twice weekly to look at data requests, figure out how best they meet those needs, and then to share the data that they need. We’re also planning a longer-term how we integrate data into a data lake and do a shared database so that we aggregate not only clinical data from the EMR but all of the different research that’s going on into one pool. So, it’s not a going back to comment before about 80 percent people, 15 percent process and 5 percent technology. It’s not a technology challenge and aggregating data or deciding where to store it. It’s about who has access to it and how do we make that access necessary available to the researchers and the clinicians who need it at any moment.

Paddy Padmanabhan: Now, let’s come back to AI which you brought up a little while ago. Now we are seeing significant advances in AI and machine learning tools and it’s being applied in the healthcare context in a wide variety of ways, both on the clinical as well as on the administrative side of the business. However, the sense I get is that for a vast majority of health systems, analytics is mostly still about retrospective analytics and AI is still in its early stages. And those enterprises that are making progress with AI are challenged with, you know, what kind of use cases are the right ones? How do you ensure transparency in the machine learning models? Algorithmic buyers, you know, ethical issues and so on. What are your thoughts on the current state of AI and how are you deploying AI at NewYork-Presbyterian?

Daniel Barchi: Well, first of all, Paddy, I really appreciate you raising the issues of algorithmic bias and the quality of the data. The black box problem and ethical use of AI, because as we think about using advanced technology with patient data, we have to be very, very thoughtful, careful and respectful of the ways technology interacts with our patients. This is people’s health. These are people’s lives that are at stake. And so, we can’t be cavalier with it in any way. And so even at the most senior levels, led by our CEO and the two deans, we talk about those challenges and we are very careful about what we do. So that said, we do know that AI can help us do a better job of delivering care and being more thoughtful about how we’re using data. Although if you’ve seen me speak publicly, Paddy, you know, I tend to talk about the fact that we’re still in a gold rush phase of artificial intelligence in healthcare, where if you think back to the gold rush of 49. People who made the money were not the miners who were using the picks and shovels to dig gold out of the hillsides. It was the people selling them, the picks and shovels. People like Leland Stanford, who accumulated money and was able to underwrite Stanford University or Levi Strauss, who is selling clothing and blue jeans to those miners. And so, I feel like at this point with artificial intelligence, the gold is not the clinical side of it. Equate the physicians and nurses to the miners. The gold right now is on the back-office side of it. The people who are creating the environment, the finance people, the IT people, the HR people, people who are running these large systems. And so it’s much easier to apply artificial intelligence to a billing system to make predictions about which bills will or will not be approved by a payer, or to use AI to look at documentation by a physician and see if it’s going to pass muster or use artificial intelligence to do the basic robotic process. Automation work of reaching out to an insurance company and looking up information online and aggregating that data so that somebody else saves hours of time by doing all that finger keyboard work and can more thoughtfully think about it. So, at NewYork-Presbyterian we are using AI in clinical ways, which I’d be happy to describe in a minute. But a lot of our focus is the recognition that it’s much easier. We have much more constrained data sets, meaning discrete data in the field that you can use to feed AI systems on the finance and the IT sides of the house.

Paddy Padmanabhan: Yeah, I love the analogy of the gold miners and people selling picks and shovels because, you know, unglamorous as it might sound, the people selling the picks and shovels are actually making money more consistently than were the people who were going after the shiny objects. So, I just love that analogy. Daniel, thank you for sharing that. I have seen some of your presentations where you talk about the robotic machine that carries the food between floors and releases the people in the kitchens to focus more on the food preparation. Doesn’t sound like the sort of thing that you would expect a hospital to be focusing on from an artificial intelligence standpoint. But that, to my mind, illustrates where the gold actually lies in today’s content. Would you sort of agree with that?

Daniel Barchi: I would agree. If you think about the fact that healthcare is a very labor intense business because we rely on the clinical skills and compassion of our physicians and nurses. The question is how do we give them more time to do their work and how much of all of the other administrivia can we take off of their plates? So the example that you just gave of the autonomous robots that we run in one of our large academic medical centers from the kitchen in the basement, down the halls, they’re robots automatically call the elevator and take the food trays directly up to the right floors and deliver it to the right area. So, a person can deliver the last 20 feet of the patient’s room. That’s an example of technology doing the basic work so that the people who are actually delivering the compassionate care, in this case, our food service workers have more time to deliver each meal personally to our patients. Ask them how they’re feeling, get a sense of whether the meals are meeting their needs and focus on those individualized patient needs. So, I feel like more and more AI will blend into care. But for right now, the big opportunity is taking tasks off of physicians, nurses, finance people, IT people and other support services that otherwise get in the way of the way we talk about that care.

Paddy Padmanabhan: It’s a fascinating example to me. So, in the remaining few minutes that we have, I wanted to walk through a few other topics really quickly with you. We do something called a lightning round where I ask for the top of the mind thoughts on some emerging technologies. Let’s get right into it. Let’s start with this one – cloud computing.

Daniel Barchi: Cloud computing is important. 10-15 years ago, every health system was very proud to talk about its data center and the investments it was making. And now we think, you know, do we really even want to own data centers? How can we get out of the data center business? Our skill set and healthcare is delivering outstanding care and making people’s lives better, not in running large facilities with a track and other fire suppression systems. So, I would like to put more and more what we do into the hands of third-party companies that do it really well. When we have to store data in its own state, I would be happy to do that using a large cloud computing system. The challenge is most large academic medical centers, in fact, healthcare generally is a relatively thin margin business and not for profit side. So everything that we do has a cost component to it and it’s relatively cheap to own a data center and keep servers in there in every two to four years as is appropriate, replace a five thousand dollars ten thousand dollar server, which is a capital cost. It’s much more expensive to pay a third-party company, an AWS or a Microsoft to store and manage that data for me as an operating cost year over year. So one of the challenges that many of my colleagues and I across the nation are finding is that we make them move to more, more cloud but cloud tends to be expensive operationally, I think that there are advantages from the security and reliability and a backup point of view. But we do face the challenge of the cost.

Paddy Padmanabhan: Yeah, OK. Next one on the list – voice recognition and natural language processing.

Daniel Barchi: I think that 20 years from now we’re going to look back on the state of healthcare and quite frankly, the state of technology in the United States and think, can you believe that the interface between somebodies brain and the computer was their eyes and their fingers and that we made people type into things? I think it’s going to get replaced over time by certainly voice and then other ways for people to ubiquitously transfer their ideas and thoughts into our systems. And so, voice recognition is the easiest way to get quickly to the next step. We’re starting to make investments in small companies that are doing voice recognition. We’re exploring artificial intelligence and voice recognition, listening to the conversations between physicians and patients with the patient’s consent so that the doctor can focus on the patient and the computer listens and documents what the physician says in terms of the current situation of the patient and what orders he or she needs to be placing. And so, I think voice recognition is going to get very important very quickly.

Paddy Padmanabhan: One of my previous guests, David Quirke, CIO of Inova Health System, he said in another 15 years from now we’re going to be in keyboard less environments. Do you think that’s something that we’re heading towards?

Daniel Barchi: Absolutely. I think there’s going to be much more optical character-driven management of our technology and a lot more voice recognition. You start to see it, although the order in the industry for its interfaces tends to be about 5-7 years behind. You can see the auto industry trying to free people from being having to touch anything and do more voice recognition. I see that happening in healthcare as well.

Paddy Padmanabhan: OK. Automation and RPA. I think you made a reference to RPA. But what do you think of those two?

Daniel Barchi: RPA, especially on the back-office side, especially in our finance side, we employ hundreds of really talented people on our finance teams who do repetitive tasks. We would rather have those people drilling down deep into solving problems, but for our health system and for our patients on a billing point of view instead of doing repetitive tasks they do today. So, we employ many bots and we’re expanding our fleet of bots to make us more efficient on the back office robotic process automation side so we can get more customer focus. And I think that’ll increase not only here NewYork-Presbyterian, but it’s happening across healthcare and it’s happening in all industries as well.

Paddy Padmanabhan: That’s correct. That’s correct. Last one in the lightning round, 5G networks.

Daniel Barchi: I think right now 5G is really high on the hype cycle and really low on what it’s going to deliver. If you think about what we’re able to do, both on the consumer side and on the business, side using wireless today, it is quite incredible. And in many cases, we’re still operating in a 3G or early-stage 4G. I think that 5G is being touted as something that is remarkable, going to change what we do. But if you really drill into the examples that people give about being able to do robotic surgery from across the world. So that’s possible for 5G, but it’s possible in a wireless or even a wired environment today. In many cases, being able to do something wirelessly is good, but not a crucial must-have. And if you think about it, every one of our ORs is wired for everything that we need. And the ability just simply for something to be an air gap in the data transfer is no real advantage. And in many cases, we’re not limited by speed either. One of the consumer things touted by 5G companies is imagine being able to download a two-hour room movie right before you get onto a plane. It’s not how people watch movies anymore; they don’t download movies onto their devices. They stream them in many different ways, including, you know, 20000 feet on an airline. So, I think that 5G right now is a outstanding technology looking for the kind of problems it’s going to solve. And I’ll add one more thing. I don’t think we’re spending enough time talking about the downsides of 5G. So, at the higher frequencies of 5G, the blanketing of cities that we’re going to need with higher frequency, shorter range antennas are not something we’re spending enough time thinking about. So essential in every light pole in every city we’re going to have 5G antenna, 5G touted to solve some of our rural wireless problems when in fact 5G doesn’t have the range that some older systems have. And so, I think that’s misleading. And if you think about hospitals, they tend to be older buildings that might be 20, 60, even 100 years old with thick walls, with lead-lined areas for imaging. And 5G doesn’t have the penetration that some other systems do. And so, we’re going to have to have repeaters in just about every space or room. So, these are the challenges that I think we need to face and that we’re not talking enough about as everybody benefits of 5G.

Paddy Padmanabhan: Yeah early days yet. So, you mentioned something about startups and working with startups early on into the conversation. And I have to ask because we are now seeing a lot of venture capital money pouring into literally hundreds and hundreds of digital health startups, many of whom have very promising solutions and are making great progress. Others that are not, but from the point of view of the CIO of a large health system looking to harness innovation, how do you go about really managing the risks and how are you doing it at NewYork-Presbyterian? What’s the advice you have for digital health innovators who want to be a part of your journey?

Daniel Barchi: So, the way that we manage the risk is that we are clinically driven, not technology or financially driven. So, we go to our Chair of Medicine, Chair Surgery, other clinical leaders and ask them what do they need? And ultimately, they’re the ones who say, here’s a promising technology or this small startup fills a gap that we don’t otherwise have. So, we don’t find technology to search for problems to solve. We go to the clinician to ask him what problems they have and then try to find things that meet their needs. And then once we find them, we do a lot of due diligence before we enter something into our health system. We have a program management office that looks at things from a financial, from a risk, from a technology, from a patient privacy idea, even from an algorithmic biased point of view before we embrace technology. So that’s from our side of the house. If I was on the startup side, I would get deeply embedded with clinical partners who know today’s problems. Unfortunately, there’s a lot of money and a lot of brilliant ideas in small companies. They’re working in healthcare space, but if they don’t have clinical insights, then they can be creating the world’s greatest X, whatever X is, and not recognize that a physician would look at that and she would say, that’s not what I do. That’s not my problem. It’s great idea, but it’s not going to work in my practice. So, thinking about things purely from a clinical point of view, first, would physicians use it? Would it make clinical care better? And then everything else to follow is really important mindset for a small startup or venture capital or private equity company to have.

Paddy Padmanabhan: Yes, that’s very insightful. Thank you for that. Well, we are in 2020. And would you care to share what your top priorities are for the coming year?

Daniel Barchi: So just like over the past couple of years, my top priority is reliability and integration. So, it’s my responsibility and that of our team to create new technologies and solutions. But for our clinical end-users, the doctors and the nurses that deliver the care, they want to see things integrated in a holistic, easy to use package. And so, while we’re constantly advancing the care that we’re delivering with great technology, it has to be part of a seamless environment. So, undoing and this is not just unique to our health system, but all health systems across the country. Undoing 20 plus years of worst of the breed and tying it together in easy to use integrated packages is our challenge. And it’s incumbent upon IT leaders to think about end-users and how they seem to use technology in the environment that they’re in. And that’s all going be our focus for 2020.

Paddy Padmanabhan: Daniel, thank you so much for taking the time to share your thoughts with us. It’s been such a pleasure speaking with you and I wish you and your team all the very best for the coming year.

Daniel Barchi: Thanks for having me Paddy, I enjoyed it and I appreciate what you do with the podcast.
Paddy: Thank you very much.

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

Daniel Barchi is SVP and CIO of NewYork-Presbyterian, one of the largest healthcare providers in the U.S. and the university hospital of Columbia and Cornell. He leads 2,000 technology, pharmacy, informatics, artificial intelligence, and telemedicine specialists who deliver the tools, data, and medicine that physicians and nurses use to deliver acute care and manage population health.

Daniel previously led healthcare technology as CIO at Yale and earlier as CIO of the Carilion Health System. He was President of the Carilion Biomedical Institute and Director of Technology for MCI WorldCom. Daniel graduated from Annapolis, began his career as a U.S. Naval officer at sea, and was awarded the Navy Commendation Medal for leadership and the Southeast Asia Service Medal for Iraq operations in the Red Sea.

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About the host

Paddy is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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AI predictions need a thoughtfully designed closed-loop to drive action

Episode #32

Podcast with Mudit Garg, CEO and Co-Founder, Qventus

"AI predictions need a thoughtfully designed closed-loop to drive action"

paddy Hosted by Paddy Padmanabhan

In this episode, Mudit Garg discusses the evolution of Qventus and how they are applying AI to help hospitals and health systems in managing their operations with real-time predictions for improved care delivery.

With a focus on patient flow automation, Qventus helps hospitals and health systems in reducing the length of stay and other operational metrics. Based on early insights that machine learning models and prediction scores can be confusing to users in the absence of an accountability engine, the company has developed an interdisciplinary approach, augmenting AI with behavioral science principles to drive sustained improvements in healthcare operations.

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Welcome to The Big Unlock podcast where we discuss data analytics and emerging technologies in healthcare. Here are some of the most innovative thinkers in healthcare information technology talk about the digital transformation of healthcare and how they are driving change in their organizations.

Paddy Padmanabhan: Hello again, everyone. This is Paddy and welcome back to my podcast. It’s my honor and privilege to have my special guest today, Mudit Garg, CEO and Founder of Qventus. Mudit, thank you so much for joining us and welcome to the show.

Mudit Garg: Thank you so much, Paddy. It’s an honor to be here. I appreciate the chance to be here. I’m looking forward to our conversation.

Paddy Padmanabhan: Wonderful. So, let’s get started. Tell us briefly about the company and its evolution and what is the marketplace need that Qventus is trying to address?

Mudit Garg: Yeah, it’s a great question. So, we provide a solution for hospitals and health systems to manage their operations in real-time. And specifically, where we focus is patient flow automation. So, reducing the length of stay, excess days in the inpatient environment, improving the throughput in the ED environment, things like that. Our platform has both artificial intelligence and behavioral sciences built together. And what it does is it empowers frontline managers so that they can identify, predict bottlenecks before they happen. But not just stop there but orchestrate solutions, drive accountability long term. And we layer on top of that a set of operational experts to bring those new capabilities to life in the hospital environments with process design and management practices alongside. So, that’s the market need where it comes from, as you know, is this immense pressure on hospitals and health systems across the country right now to drive a lot more efficiency. And this has been true for some time. You asked about the evolution of the company. And for me, a lot of this came from probably 10 to 12 years ago, doing process and performance improvement in health systems. And I don’t know if you probably felt the same way, but I definitely thought working in the hospital the first time that it was remarkable. The quality of the people; world-class equipment, world-class therapies, world-class clinicians are available at most hospitals that we work with. But on the other hand, as a patient, we really struggled to provide them with world-class care. And it’s really despite immense diving catches and super-heroic efforts from these clinicians. So, it’s really an odd dichotomy that those two things exist simultaneously. So, the market needs really, as we dug into it and as I dug into it early on, was how do you create operational reliability? How do you make everything else around the clinical care, reliable, repeatable and mature, so that world-class operations can exist to truly unlock the potential of people? So that’s kind of where we started from. The evolution of that has been very interesting. I was, you know, maybe biased a little bit to look at data. That’s one of its key ingredients to create that operational reliability from the beginning. But it was very clear in the beginning when we started focusing on AI and ML that the prediction was very important. The prediction of the bottleneck was very important, but not enough to drive that. That was the first phase of the company. We went from looking at the data and seeing that people were excited about dashboards but didn’t log in when they got busy. People decide what machine learning, but just putting a machine learning score and board didn’t do anything, that didn’t drive any action and what really needed was action. So, we built a really robust platform then that can take different parts of a machine learning distribution of a prediction and activate different decisions and action, over mobile, over boards, over email, over text, many, many different mechanisms. And that was really valuable in fact getting the insight into action. But as is the case with everything we saw that in the immense scale that exists in an operational environment like a hospital, things slowly started reverting back to the mean. So, then we built an accountability engine. And what this does is remarkable. If you’re in the world of manufacturing, there is something monitoring every machine so you can do preventive maintenance in the machine before it breaks down. Similarly, if you’re in a health system environment, there’s tons and tons of processes going on all the time. What sequence and preventative maintenance can you do? And that’s really behavioral. Right. You could have if you’re seeing this unit do a phenomenal job of planning, how can you make sure as a leader you can praise them? If this unit the person has changed or somehow the quality of the process is dropping, how can you actually make sure that there is coaching involved at the right time? Our statistical monitors are monitoring all these process metrics continuously and then searching opportunities for praises and opportunities for coaching for leaders so they can scale themselves. So those are the different phases of a company going from just information and dashboards to machine learning and prediction to action, to then the accountability engine coming through. And that was a core of the platform that we built in our evolution. I’d say the last probably evolutionary phase is recent in the last year or so. Whereas we went deeper and deeper, the market, we saw that to truly bring these capabilities to life; we needed to create a set of predefined best practices of how to use these capabilities where there’s predefined artificial intelligence models of software, but also operational processes and management practices, and then put together a team of world-class experts on clinical operations, doctors, nurses, AI experts to help bring all this to life. So those have been the evolution in trying to address that market need through the course of the company.

Paddy Padmanabhan: Very interesting. There’s a lot to unpack from what you said. A couple of things that come to my mind right away that no matter how good a solution is unless you’re integrated into the clinical workflow of a hospital, it’s very hard to get users to adopt it and use it. And so, it seems like that was kind of one of the early insights you had, and you quickly went about addressing that. What I do like about the fact is this closing the loop, if you will, in terms of getting people to not just to use the platform, but holding themselves accountable in some ways through some kind of a feedback loop which tells them how they’re doing in order to avoid the reversal to the mean, which, as you know, is the bane of all management consulting. That’s right. Interesting. We’ll unpack some of that. Just tell us a little bit about from a growth perspective. I’m aware that you raised a significant amount of venture capital. Do you want to just quickly walk us through how much you’ve raised, who your major investors are?

Mudit Garg: Yeah, absolutely. I think from a growth standpoint, we’ve been fortunate in partnering with our health system partners to see growth in the work we do with them and concurrently, therefore, in the investment and that we can make in growing the company as well. We have raised to date about 45 million and we’ve been very, very blessed to have some very top tier investors from the valley and in the healthcare specifically as well. Some of the largest investors are Mayfield, Bessemer Ventures, Norwest Ventures. We also have YCombinator as a very early seed investor in the company and many other phenomenal seed investors in the company. And what’s been amazing is also some of the customers who work with us also felt compelled enough by the results they have seen to become strategic partners in investments as well.

Paddy Padmanabhan: But are you allowed to name any of your customers? You want to name one or two just for our listeners?

Mudit Garg: Yes. I mean, Dignity and New York-Presbyterian are two are the ones that have actually both been customers, but also investing in the company as well.

Paddy Padmanabhan: Dignity and New York-Presbyterian, is that what you said?

Mudit Garg: Yes.

Paddy Padmanabhan: OK. All right. Switching back to our topic at hand, which is your solution and your platform? How do you see yourself in the context of the ecosystem in which is the technology ecosystem in which you operate, namely electronic health record vendors, big tech firms that are building a lot of the capabilities that you’ve talked about in terms of advanced analytics, AI, machine learning-based decision making. And last but not least, other digital health startups who may be on to the same kind of ideas that you have. How do you place yourself in the context and in the milieu?

Mudit Garg: Yes. So, yes, you’re right. I mean, it’s a really exciting time to be in healthcare. That is just so much innovation and excitement across the ecosystem. I mean, to start with, EHRs are supercritical right there. We complement the investment health systems have made in the EHRs. Without that, we wouldn’t exist. If the data and the workflow itself wasn’t digitized, it’d be impossible to drive any kind of improvement. What our customers have found is that they’ve made substantial investment, in these areas of operational improvement over the years, both in terms of, you know, it could be in terms of process improvement, it could be a technology investment. If you look at the length of stay across the board, for example, that has really not budged much over the last 10-15 years, it’s been increasingly plateaued. So, when they look at looking to partner with us, what they’re looking for typically is the next step function improvement. And what really stands apart is, one, let’s take the inpatient, for example. In the inpatient environment we aren’t just helping you provide an understanding of [00:09:39] the workflow as isn, but our machine learning algorithms are, A) Identifying the problems, like this patient may need an MRI upfront several days in advance, then helping orchestrate the action and then helping manage throughout the ability. That’s super unique because one of the things that you do talk about the closed-loop part of it, just providing the AI/ machine learning is simply not good enough, in fact, and can sometimes be even more confusing to end users but closing that loop, providing the AI/ machine learning, helping create the action, and then helping create long term sustainability. That’s what is supercritical to our customers. And that’s where they see it most different. Of course, EHRs are pretty critical in view of the process improvement consulting teams that exist are pretty critical ingredient from a mindset standpoint, do all of that. But this infusion of AI and behavior science, not just AI, but the behavior science of, we think of like, how do I change behavior as a human? I need to have a cue, something prompting me to do something. I need to have the right thing to do. The easy thing to do. And I need to have some feedback on accountability. We have incorporated those vague principles in creating this organizational behavior change as well.

Paddy Padmanabhan: Yeah, fascinating. So, is it fair to say you mentioned length of stay a few times? So, is it fair to say that, that is one specific problem that you’re focused on and have been able to demonstrate results, and by extension, is that kind of the main use case for your platform?

Mudit Garg: So, our platform is fairly extensible. Patient flow ends up often being the first-place customers start because as one of the things for health systems among many, many things they can do. Length of stay and patient flow is something that no matter where in the spectrum of fee-for-service to the value-for-service organization you might be, It’s one of those rare problems where the incentive of the customer, the patient, the incentive of the hospital, of CMS or the payer are all aligned. No one wants the patients to have to stay an excess amount of time in the hospital. The patient doesn’t want that, payer doesn’t want that, the hospital doesn’t want that. So that is an area where we’ve seen a tremendous amount of pool as a result from the market. And increasingly as hospitals and health systems look at Medicare break even. How do we break even on a Medicare patient long term? Length of stay is such a massive part of that problem that we’ve seen a strong amount of pull there. But our platform extends beyond that to throughput in the E.D. and the operating room. We have worked in the outpatient access space. We are working on system operations similarly as well. But for most health systems inpatient as a state has been a place that they have had a strong interest and often a place to start with us. We have seen, as you asked the question, pretty significant improvements there as well. Statistically significant reductions in length of stay between 0.2 to 0.7 days, which is phenomenal. If you’re in a capacity constraints institution and being able to serve more patients and if you’re not in a capacity constraint, information in terms of being able to reduce the cost to serve patients.

Paddy Padmanabhan: So, it is a business case, fairly straightforward. Because it is a single number that you can track, which is length of stay. And if you reduce the length of stay by a factor of 0.2 or to 0.7, as you mentioned, the results kind of automatically speak for themselves and they are visible. Is it a fairly straightforward business case?

Mudit Garg: The business case is straightforward. The problem is complex. Yes, I think that would be a fair assessment. The business case, I mean length of stay is a top initiative for many, many health systems in the impetus to drive down unnecessary cost. And so therefore, that already exists. Any excess their patient spends is at least a thousand dollars of excess costsin the hospital. Along with the propensity to have a hospital-acquired condition or infection or other pieces and the lack of satisfaction that comes from it. So not even counting for those other downstream effects just a core excess cost is significant by itself.

Paddy Padmanabhan: Yeah. Who is your target audience for something like this? Who do you normally start conversations with? Is it a CIO, Chief Digital Officer, Chief Medical Officer?

Mudit Garg: That’s a good question. I mean, the operator is the Chief Operating Officer, the CNO, CMO. Those are ones who are already strategically often focusing on this problem, like the problem of length of stay, throughput flow. We help remove the cognitive boredom from the front-line teams that help to ease some burnout. So those are the folks that are often probably most directly eating and seeing the problem and looking to solve it. The CIO is a very critical stakeholder in the discussions right because we are complementing the EMR. They may have other tech investments. We want to make sure we have a good understanding of the data transfer and data lakes and all of those things. So, they are a critical component. And then the last piece of it, which is given the compelling financial return, the CFO are often important stakeholders as well. It can be between 10 to hundred billion dollars of annual financial benefit for assistance to the CFO and to be critical to that conversation as well.

Paddy Padmanabhan: So, if you look back at the past several years that you’ve built this business and built the platform and gone through their evolution. Can you talk to what have been the most significant challenges that you’ve faced in really validating your solution against a known problem?

Mudit Garg: So, most significant challenges in validating or are those two questions validating the solution and the challenges we face?

Paddy Padmanabhan: The length of stay problem is a well-known problem; it’s been a problem for long. So, when you went about trying to sell the idea of it. What were the most significant challenges you had to overcome in the process?

Mudit Garg: That makes sense. So, I mean, look, it is a big, big problem, right? Like when a patient, for example, is being taken care of in an inpatient environment, there are just so many things involved. There are physicians taking care of them, diagnostics taking care of them, there are procedures happening. They are going for imaging, a pharmacist helping them with medication reconciliation, so many things beingdone. It is a fairly complex problem. The first thing that we had done, and we needed to do was just to make sure we understood the complexity and size of the problem we’re going after. It is a hard problem. The next challenge is healthcare data, as you know, is often hard and messy because unlike advertising, where all the data is machine-generated, much of the healthcare data is not machine-generated. It’s human-generated, so by nature it’s messy. So, for us, one of the very core needs early on was to build a pretty significant platform capability to do real-time and automated data quality checks so we can pick up when things are off and not looking right. So, they don’t affect all the downstream applications significantly. So that was one of the big challenges, just the quality of the data, the availability of the data. How do you make sure, for example, building a machine learning model in an academic environment would control data where you can take out the outliers, where you have historical data and it has been cleaned. That is way different than running it in real-time. So, first that was a challenge to solve. The second piece is also just recognizing how much change people are going through already in healthcare on the front lines, how little time they have. And to some extent, how much fatigue or change fatigue may set in situations like that. And therefore, not just taking, hey, this is a cool prediction and putting it up on the board and expecting something to come out of it, but really very thoughtfully designing the closed loop that we were talking about. And I think that was an important challenge to recognize and to work towards because otherwise, it is easier in some ways to solve the mathematical problem that is to be solved. But forget the true problem of trying to drive change in the environment. Those I would say are probably two of the challenges along the path that we had to face, that shaped as I said in the beginning of the conversation our evolution from just predicting and prescribing actions, to actually building the accountability and getting the platform and then to actually creating these prescriptive, proven methodology combinations of tech and process that we now deployed to a team on the ground.

Paddy Padmanabhan: That’s fascinating. We hear a lot about the struggles of digital health startups, death by pilot, long sales cycles. So, on and so forth. Healthcare organizations want the innovation, they need to innovate. There is alignment around the problem to be solved to your point around something like the length of stay. But in reality, executing on an innovation program is incredibly hard. As you pointed out, should healthcare organizations be doing based on your experience so far to accelerate the adoption of digital innovation with all these constraints? You don’t have time, we have fifty other things, but we also want innovation, right?

Mudit Garg: Yeah. I mean, it is hard, right? It is really hard. I understand where it comes from because the business and the care, they are providing already is complex. There’s a lot of change in the market, so that takes a good amount of the bandwidth away from the day to day already. And so then in a way, it becomes harder. But I think what I’ve seen very effective organizations do is, one really thinks about what the no brainer moves are. We may not know what the latest CMS guidelines are going to be almost certain things. We may not know how the regulatory environment might shape. What are the no brainer things that we need to do as health systems no matter what? So for a lot of them, like reliability and cost comes to the top. Okay, so that’s that then. I think oftentimes in saying of what are the one or two or three partners we can pick and go deep with them? And that doesn’t mean you have to start with the big bang right away. It just means that, , you engage with them deeply. And I think that is supercritical. From an innovation standpoint, that it’s very hard to have a spray and pray kind of an approach where you have your hands in a lot of things or you’re just assessing the market, but actually doing it because I think for the organization to see some wins and to see some action, that’s supercritical. Honestly, even if it doesn’t result in wins, see that something was talked about, done and learnt from is critical. And the last thing I’m saying from an innovation standpoint that’s critical is that finding the operational alignment is important. The innovation cannot be devoid of what the people are feeling day to day. That operational alignment must exist. And I think in doing these three things, what we’ve found is like, for example, for us, we worked with early customers, went deep on their specific problems, created these best practices, AI models and all that stuff. So, when customers, then innovating, appreciated it. There are parts of what we do where they don’t need to reinvent the wheel and they are parts of innovation where we are learning with them and just sort of appreciating. We’re not trying to reinvent the wheel entirely. But, taking what’s already there and then actually finding unique ways of improving the innovation as well is something that I find to be effective. It is a hard space. So, the sales cycles for enterprise, in general, are hard, not just healthcare, they are long. But I think if we can do these things, then when you align with someone, you find the right partners and you make sure that it actually drives through, impacts the business and starts fueling an appetite for more and more innovation over time.

Paddy Padmanabhan: One of my guests on one of my earlier podcasts mentioned that she benefited greatly from having these sponsorship and support of some early believers and risk-takers in their client environment. And let’s face it, there is a lot of risk involved in innovation. Healthcare is a margin constrained environment. There’s not a lot of like to have. You also had that experience, you know, the early believers who make a huge difference who you co-innovate with and, you know, somehow make it happen? Has that been your experience as well?

Mudit Garg: Yeah. I mean, if you look back all the way back in the beginning, now we have a ton of outcomes and we have customers and stuff. So, it’s a little bit of a different risk profile today. If I go back three-four years ago, those same questions existed. And I think Mercy was a great example of an institution where we had operational champions, the head of their ED for example, the presence of a disintegration across the board. Folks who just jumped in, worked hard with us, understood it. But you have to have those early champions who are willing to connect the business pain to the problem to be solved, to the solution that’s coming through and help sort of get everyone excited and fired up on that. And that’s critical, especially even more so in the earlier days. Of course, as you go deeper in the market people evaluation and sort of reasons to buy change and become more and more business focused. But early on, that is absolutely critical.

Paddy Padmanabhan: Fascinating. So, guess we have coming up to the end of our time here. I have just one last question for you. You’re a classic Silicon Valley digital health startup. So, tell us what are the upsides and downsides of being in the valley?

Mudit Garg: Yeah, that’s a good question. Not surprisingly, everything sort of has this upside and downside. I mean, what I love about being in the valley is you have access to world-class talent; technical talent, and business talent. People who been at the vanguard of the AI and behavior science and innovative technology and most importantly, who have scaled businesses and transformation of industries and other industries before. And that is amazing and very, very critical to have that ecosystem around you and to have that quality of talent, it seems to be brought to bear for the problem you’re trying to solve. I mean, the flip side of that is, of course, it’s the value become extremely both costly and sometimes in that they hard to scale and just as so much of innovation comes out of here and I think over time now, a lot of the talent is actually going to other places in the country, which is phenomenal. And that’s allowing us to create much, much more of a remote enabled culture as well, where folks can still have the core of the same ethos that came out of here but actually scattered across the country and beyond. So that’s sort of the upside and downside of being here. The upside of this, that is like so the quality of talent and the experience of folks before the downside is dropped, perhaps the cost is sort of a distraction value that exists by being in the valley.

Paddy Padmanabhan: Well, not to mention the traffic on one-on-one.

Mudit Garg: Ya we’re gonna one-on-one is not a very friendly yes. Yes, you’re absolutely right.

Paddy Padmanabhan: Mudit, it’s been such a pleasure talking to you. And thank you so much for sharing your deep insights from all the work that you’ve done. And congratulations on the progress so far. All the very best to you and your team. And we’ll be watching.

Mudit Garg: Yeah. Thank you so much, Paddy. It’s always a great conversation with you. I am excited to continue the conversation. Thank you for having 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

Mudit Garg is the CEO and Co-Founder of Qventus. Qventus is an AI and behavioral science-based system that integrates with EHRs and automates patient flow. In this role, Mudit works closely with leading health systems including Dignity, Emory, Fairview, Mercy, NewYork-Presbyterian, and Stanford. Together with Qventus, these organizations have been able to transform their operations, reducing length of stay by 0.3 to 0.8 days, eliminating thousands of excess days, decreasing ED LWBS by 50%, and more – ultimately resulting in higher margins, decreased staff burnout, and a better patient experience.

Prior to Qventus, Mudit co-founded multiple technology companies including Vdopia and Hive. He also spent time in McKinsey & Company’s healthcare practice helping large providers with organizational transformation and performance improvement. Mudit has been recognized for leadership as one of the Silicon Valley Business Journal 40 Under 40. He is a Stanford-StartX mentor. He earned his Master’s in Business Administration and Electrical Engineering from Stanford University and a Bachelors from the Indian Institute of Technology.

About the host

Paddy is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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Even the small hospitals really do want to enable a modern consumer web experience today

Episode #31

Podcast with Graham Gardner, Co-Founder and CEO, Kyruus

"Even the small hospitals really do want to enable a modern consumer web experience today"

paddy Hosted by Paddy Padmanabhan

In this episode, Graham Gardner discusses how his company, Kyruus, targets patient access issues in health systems. Inspired by the Moneyball concept, Kyruus uses advanced analytics to understand patient needs and put the right providers “to bat” where they are most likely to do well, thereby reducing or eliminating variations in the quality of care.

Graham discusses the challenges of introducing digital innovation in healthcare and provides some counterintuitive advice to other digital health startups looking to overcome challenges in sales cycles and achieving enterprise-wide adoption for their platforms.

 

Welcome to The Big Unlock podcast where we discuss data analytics and emerging technologies in healthcare. Here are some of the most innovative thinkers in healthcare information technology talk about the digital transformation of healthcare and how they are driving change in their organizations.

Paddy: Hello, everyone, and welcome back to my podcast. This is Paddy and it is my great privilege and honor to have as my special guest today, Graham Gardner, CEO and Founder of Kyruus. Graham, thank you so much for joining us and welcome to the show.

Graham Gardner: My pleasure Paddy. Thanks for having me.

Paddy: So, let’s get started, Graham. Would you like to tell us briefly about your company, its evolution, and what is the marketplace need that Kyruus is trying to address?

Graham Gardner: So, Kyruus is a routing and scheduling platform for health systems that helps to ensure that patients within their network are getting to the right network provider. And the founding vision for the company was originally Moneyball. And this idea that one can use statistics to understand relative competencies amongst players and use that information to put them up to bat in situations where they’re more likely to do well. And the team, therefore, benefits from everybody playing to their strengths. And I was convinced that you know, we as physicians, the same way as ballplayers trying to hit every pitch. We as physicians, we’re trying to help every patient. And yet, statistically, we had huge variations in the care, and cost, and quality that we were delivering to patients and began to wonder whether we could get a more granular view of providers, their statistics, if you will, and use that to understand what they might be best suited to treat and put them up to bat, if you will, or match them with the right kinds of patients. And as we began to engage with more and more healthcare systems around that conversation, what we uncovered was that many of them were really struggling with the ability to match supply and demand scale. And what a lot of them would acknowledge to us was, we know patients are waiting far too long to get in and access care here. As a result, they’re either not getting that care or they’re leaking out of the network and seeking care elsewhere. What was staggering to me, though, Paddy, was when they would next say, it’s not because we’re 100 percent full. In fact, 20, 30 in some cases 40 percent of the appointments were actually empty every single day. And the reason for that was that too often patients were queuing up for Doctor Famous. You know that many of the other physicians are trained with someone at the call centers had on the shortlist to send to. But meanwhile, there might be a brand-new doctor who did exactly the same thing as Dr. Famous, and she was sitting at 30 percent productivity. So, as you kind of looked across this large network, you had a lot of demand not being accommodated, a lot of supply going underutilized. And it was only getting worse because health systems were getting larger and larger so no one really kind of knew each other anymore. At a time when medicine was getting super, super subspecialized. And so, gone were the days of my go-to ortho guy that I send all my orthopedic cases to. There was now a hand person, an elbow person, , foot and ankle, spine, et cetera. And people really didn’t have the right information to understand where to refer a particular case, that was right for the patient, right for the provider and even at the top of their system and also right for the healthcare system. Paddy, we looked into it, in healthcare you don’t have to invent anything new, you have to look at whatever else was in the 1980s and bring it forward. And so, we actually looked at the airline industry, which had actually wrestled within many ways solved a lot of the same seat utilization challenges. Turned out if you rewind back to 1990 every time an airplane took off in this country, about 4000 seats were empty. So very similar to where some of these health officials found themselves today. And what had transformed that industry were things like the Saber system that ultimately became the likes of Travelocity and Kayak, it depicts the idea that on one screen you can look across all the providers, you could look across the American Airlines or Continental or JetBlue, in our case, doctors, that might be on the Epic scheduling system, the Cerner or Athena, you could sort and filter by business logic. So, if I wanted to take off after 9:30 and sort by price, I could click and do that quickly. In our case, if I felt more comfortable as a female provider that spoke a certain language, I could again click and find who as soon as available and basically book in and get that seat, if you will, on a single platform. And so that really became the model for how we thought we could help the health system achieve operational, financial objectives. But most importantly, get the right clinical care to each of its patients. So today we work out about 600 hospitals around the country, about 250,000 providers on the platform and continue to enjoy partnering with health systems and increasingly partnering with other companies as well that really kind of that overall patient access solution.

Paddy: Fascinating. How long have you been around?

Graham Gardner: I’ve been around for about 9 years.

Paddy: Nine years. So, you know, I really like the Moneyball analogy that you made. And that, of course, is very catchy and intriguing at the same time. And of course, you’re addressing a problem that is all too well-known, which is patient access, which comes in many shapes and forms in terms of its impact on a particular health system. The utilization rate is obviously one which is very, very visible because it has immediate revenue implications for the health system. And I’m very familiar with this problem. So, let me ask you this: when you start working with health systems, how are they addressing this problem today? And can you give us an example of how you used, let’s say, a proprietary algorithm that you developed to help them get better at what they do? Can you maybe illustrate with a simple example?

Graham Gardner: Yeah. So, it’s very much an industry in transition. I think when we first started, to be perfectly frank, organizations were working on paper and, you know, go into call centers and you would see an agent desk, cluttered with different kinds of paper. There might be a binder that had, profiles in our directory that have been printed out, a year ago and was likely updated the minute it was printed. There might be special instructions scribbled down with someone’s back-office number there as a posted note. You know, Dr. Jones doesn’t take patients on Yankee game days and has a poor scheduler, who is very much the front line and the first voice into a healthcare system, is having to look in all these different disparate datasets to try to route someone to the care. And I think that really was so much of what accounted for the inefficiency and being able to kind of make that match. The second thing you still see today, Paddy, is that different parts of the organization we’re working with different solutions. And so, you know, there might be still a print directory going out to all the referring providers. And that was where people were getting their information there. But the marketing team that was running the website might be compiling a different set of information and they might be doing outbound phone calls to the practice to try to keep the address current. Or they might be sending out surveys to the doctors to try to do that. Then the call center might have a completely different set of information that might includecredentialing. And too often with that different information, the poor patients were seeing real inconsistencies across that. They might get a name from their referring provider. They go online to do some research and actually they’re looking at a different specialty or something like that. Then they call into a call center, book the appointment and find out the person is not even working there anymore. And so, again, there’s a real lack of standards and the right tools to do that. I think people began to look in different places for solutions. Many then turned logically, they do to their EMRs, what they could learn there. But EMRs are really not built to do that kind of keyword searching and routing and certainly not across different EMRs as well. So, I think it’s for that reason, Paddy, that a lot of them begin to look to us to see what we could put across this different EMR as a platform to kind of enable that that routing.

Paddy: So, I want to kind of unpack a couple of things you said. As far as the provider matching is concerned, there are two aspects to the problem. One is the quality of the information as it relates to the provider data and the other part is actually finding intelligent ways to direct the patient traffic in ways that help a patient get what they need. And also helps distribute the workload in a way that the overall utilization level goes up. Are you addressing both problems or just one of them?

Graham Gardner: Yeah. Great question Paddy. We are, although I would say I’ve been surprised in our journey how much of it is still today, the basic data management. So yes, when we first began talking with health systems, our hope was that we could use a lot of data to uncover who is most efficient or most effective in different areas. And what we heard from a lot of health systems early on was, look, we just want to figure out who our doctors are, and we can simply get knee cases for the knee surgeons and hand cases to the hand surgeons. You know, that’s a huge lift for us. And so, a lot of the work that we do today, Paddy, is really compiling very robust profiles of providers. We do that by tapping into dozens of different systems. We bring around 200 different data elements to bear in a profile. So, the data element might be a personal statement, it might be a specialty training location, it might be a back-office number, things like that. And so, we pull those from different systems. And a lot of the work that we do is not only integrating the data. So, for example, I might be Graham S. Gardner, M.D. there and Dr. Graham Gardner over here and, you know, scale making sure those are the two same identities. But actually more important is really the governance around that data. So, for example, as I was alluding to earlier, a location might be pulled in from a credentialing file, but that only gets updated every two years when someone’s re-credentials. It might be in the marketing database, so they’ve made outbound phone calls every six months to verify where someone is, but it’s also in the senior practice management system where the provider seeing patient’s tomorrow morning. That’s probably the most accurate one. And so, we do a lot of that work early on and engaging with the health system to understand where to pull the information and then set up all those feeds to make sure it’s current and governed and sign off around it. That’s the first part. But then where we next go, Paddy is enriching that data with the clinical library of terms, conditions, procedures, diseases, and things like that. We over the years, beginning with claims data analysis that then really curated with a lot of clinical experts and now our clients as well. It’s been a developing 25000 term library of conditions and procedures that we crosswalk to the different sub subspecialty. So, when we onboard an organization and identify, eight peripheral interventional cardiologists, they get assigned anywhere from a hundred or 250 terms to describe the typical practice of a peripheral interventionist. Oftentimes that provider, whether their practice manager is actually engaged in that process and actually further curates and can actually do at the condition leveltell us what they want to see in their practice. And that, Paddy, is a huge physician engagement piece to what we do because I think for providers who are working really hard and suffering a lot of burnout, the idea of a robot coming in and filling up their panel and getting it wrong, is understandably really scary thing for them. And so being able to kind of extend them a tool that says, look, we actually understand exactly the kind of patients you want to see and we’re not going to be responsible for sending you a knee case if you’re actually a hip surgeon. So that it is really kind of invites them to be a part of that process. And the first step of beginning to kind of ensure that quality is being accounted for. Well, you’re getting people to the right people for that care. We take additional data sources, for example, pristine scores and things like that so you can begin. First of all, you can publish that to patients, but also potentially, rank how you distribute care based on those scores as well. So, we’re beginning to take more and more steps into quality metrics and things like that so we can ensure that the data is right, but also that the organization begins to operationalize the strategy for how it wants to distribute patients within the network.

Paddy: Right. So, who is your buyer for a solution like this? Chief Marketing Officer, Patient Experience Officer, who is your first protocol for something like this?

Graham Gardner: Yes, Paddy, this has really been one of the challenges. But I think something that we’ve embraced and do much more effectively today. So, the reality is, as I described, that of a multi-channel approach to scheduling and patient access, there are a lot of leaders in the organization thinking about this and looking for solutions. And so, we’ve gotten very comfortable talking with a number of different stakeholders and quite frankly, can vary by organization, Paddy. So, you know, one example, it might be the organization decides to centralize their call center. They brought 200 agents onto the same room. And it’s really the, head of access to the COO that’s now looking for a technology platform to help enable those agents to be as effective as possible. Another organization that might be Chief Marketing Officer who is, competing with the organization down the street that’s now enabling online booking. And she now wants to enable that for her organization. And so, it starts off much more like a digital front door type of conversation. In others, it’s around trying to stitch together clinically great network and its clinical leadership that’s beginning to look at that. So, we oftentimes will start a conversation in various parts of an organization. What we do as part of that conversation is to try to bring those leaders together. And even though we do sell our package in modular ways, we have a call center package, web site package, and then a more of a distributed point of care package. Organizations can buy one or more of those. But we do like to engage all those leaders in the conversation right upfront to help them understand the power of standardizing on one platform across all that. So, all those leaders, obviously the CIO and the IT infrastructure has to be engaged. We’re tapping into many of their different systems. And ultimately the CFO is often the one writing the check and really seeing and appreciating the benefits of taking an organization that may only be at 60 percent utilization of its schedule and deriving that 70 percent. And, you know, a multibillion-dollar organization has a profound financial impact.

Paddy: Yes. Well, I’ve been in healthcare tech a long time and one thing that we all know about the provider ecosystem is that the sales cycles are very long, and I just think from what you just said that adding a layer of multiple stakeholders that you need to convince. Does that make it longer? Does it make it more challenging and difficult for someone like you?

Graham Gardner: It does. It certainly makes it longer, without question. And yet, Paddy, I think what we feel is that it positions the company very well because no other company has really taken the same approach to incredibly robust data management. And then that multi-channel approach to matching across all the different access points for an organization. And so, it really kind of positions as well as the single vendor that can really provide that solution for folks.

Paddy: You may have answered this question already, but in terms of ROI do you demonstrate it in a very straightforward way by just showing higher utilization rates or how do your stakeholders make a business case to invest in a platform like this?

Graham Gardner: Yeah. That’s been a very important part of our conversations with clients. I’m a cardiologist by training Paddy. And so, I grew up in the world of clinical studies. And, you know, from day one, we instrumented the tool to really begin to understand the impact of what we were doing. We think about it in different areas. So, one is really around patient acquisition, and this is, I think, easiest to demonstrate on the digital channel. You know, when you take an organization live and now enable patients to book online. We see tens of thousands of patients within a month start to book online. And what’s incredibly exciting for these organizations that oftentimes half of those patients are brand new to the system. So, they were you know, they were shopping, and consumers are starting to vote their feet. And if someone allows them to book online, they will select that at 8:00 at night and book in. So that was very exciting for them. Eighty percent of the patients are commercial, by the way. So, if, as you know, of course, I have to think about the business side of medicine, you know that’s obviously exciting for a client. But the other aspect of it, which I had not picked up on early, but talking with our clients about how much they appreciated this year, that’s 10000 phone calls, Paddy, not going to a college. And so, from an operational burden perspective, you’re actually acquiring those patients without staffing up a call center and things like that. That’s been exciting for people on the kind of acquisition side of things. What we see on the retention is a 50 percent reduction in leakage, 50. And this is always something that I believe would be able to demonstrate when I first started learning about this industry and hearing terms of leakage or patient outmigration. You know, I was convinced, Paddy, that the patients aren’t referred out of the system because doctors are bad people trying to sabotage the system. They honestly just don’t know who their own colleagues are. And, you know, their go-to person is now Dr. Famous who can’t see people for months. That patient needs care. And so oftentimes, yes, they will leak out of the network. And what we found is that if you do provide a tool now for people to find their colleagues and they will do the right thing and refer in-network and really keep that care coordinated with the same EMR systems and all the rest of it, so that’s been exciting to see. In the last, we just really kind of home run metric is going back fill the schedules. And so, what’s exciting is we will take a baseline of the schedule a year before we go and then measure that again a year later. So, you can get a comparison of the flu season. And sure enough, we increase schedule densities anywhere from 2 to about 11 percent, which doesn’t sound huge. But then again, when you talk about a multi-billion-dollar organization, if you’re bringing in, 10 percent more patients at the top of the funnel, it generates tremendous amount of downstream radiology and labs and procedures and things like that. It’s been very exciting to build it and demonstrate that with customers.

Paddy: Yeah, I know. That’s a nice segue to my other question that I was going to come to. You mentioned these are multibillion-dollar organizations. And we talk about digital front doors and clearly that’s making a huge difference in terms of access. But is there a certain profile to whom this kind of a solution is more applicable and more beneficial than others, for instance? You know, I don’t know that community hospital in a city environment. I don’t know. I’m just asking, is this more applicable to them versus maybe a big city hospital in Boston? Is there a sweet spot? Is that a kind of an ideal sort of a health system that can get the most out of your solution?

Graham Gardner: Yeah. So, you know, nine years ago, Paddy, my mind thinks exactly where yours were, which was, you know, that the larger and the more academic an organization, the more I could utilize this. Because you know that there really is a left nostril surgeon who doesn’t like the right nostril surgery and, be able to kind of really find that needle in the haystack was going to be somewhere where we could shine and allow people to really filter down by a number of different things. It’s also where you’re getting a lot of complexity in multiple different systems for the benefit of a platform sitting on top of that and standardizing everything was going to be really beneficial. And so, for the first several years that really had been what we targeted based the top 400 health systems or so in the country. Oftentimes they’re in very competitive metropolitan areas. And so, again, that they really are looking for something that can differentiate them from what I would say, though. So, over the years, we’ve begun to go down to smaller and smaller organizations that I think particularly around the digital front door. Paddy, I think, you know, in the call center, look at there really only are two orthopedic surgeons. Everyone kind of knows who does what in a small hospital that’s maybe less compelling. But everybody, even the small hospitals right now really do want to enable a modern consumer web experience. And to the extent that involves rich data and videos and the ability to book directly online, that is something we provide. And as we’ve developed our own solution and now scaled and operationalized the way that we can, you know, onboard an organization that size more effectively, we’ve been able to keep going in that direction. So, we haven’t found anyone too small for us yet. We certainly don’t do small physician groups, so we don’t do the 18-person orthopedic group or anything like that. But we do a wide range of healthcare systems.

Paddy: That’s interesting. So, let’s take a step back and look at the broader picture here. Now, you are part of the digital health ecosystem of billions and billions of venture government money that’s pouring into innovative startups. Some of them have done very well, others are struggling. Based on your own experience, can you talk about what are some of the biggest challenges that you have had to overcome? You’ve been around nine years, so that is long enough for me. So, talk to us about a couple or two or three of your top challenges that you’ve had in your journey so far.

Graham Gardner: Yeah, honestly surviving is one of the key things these organizations move very slowly, particularly when you’re trying to introduce a new market concept or segment that we were very lucky early on to find wonderful champions that could take us to organizations. But there really is a lot of alignment that has to happen. And, you know, we watched our own space, mature over the years, from something that one or two people saw. You have the likes of Aaron Martin, such a forward-looking thought leader in this space to this really becoming a CEO level initiative that now, the C suite was responding to and had a budget to go out and fund. And so, I think part of it is surviving and raise the venture capital support, which has been terrific to allow us this to kind of live long enough, quite frankly if I wonder the market wakes up. I think that’s one part of it. I think the second part is really having a humble approach to the industry. I think that maybe less so today. But certainly, when we were starting, there was a lot of feeling that healthcare people are behind, know they’re 30 years behind everybody, they don’t know how to do things. We can come in and just solve things from a tech perspective in a much more efficient way. And the reality is that healthcare is different. You know, I will use the analogy of airline seats for what we do. It’s finding the right provider is more difficult than booking a seat of Chicago on American Airlines flights. And so I think coming in with that humility and really listening and understanding, these are people who care deeply about patients and not making mistakes and, you know, people to sell to hard [00:32:04] snake oil salesmen. I think this industry is trained to repel that. And so, it really you have to bring credibility and listening skills, I think, in order to kind of understand the challenges. And then I think the third thing, and this is something that we’ve figured out over time, Paddy, is how to be the right size. And what I mean by that is that so much of what I see, you know, even getting funded today are point solutions and end up in the pilot world. And if you don’t have broad organizational buy-in, it’s very, very hard to scale something like that, and it’s so easy these days to spend 10,15, 20 thousand dollars on something but really not get buy-in. And so, there’s a certain surface area that I think you need to speak to in order to be noticed, quite frankly. And you know what we’ve noticed, Paddy, over the years as our deal size has gotten larger, it commands more attention from the organization and those end up being much more successful implementation than customers because there really is that buy-in across the organization. So, I think being big enough is one thing. But then I think on the other extreme, Paddy, it’s not trying to boil the ocean and do everything. And so, a lot of where I’ve been spending my time over the last year or so has been in forging a number of business development partnerships with other vendors and technologies that serve the healthcare system. So, you know, the example we announced the deal with Salesforce, and you have an embedded turnkey solution now within their CRM because the reality is that health systems are looking at both scheduling but also CRM. And so, we’re doing more of these kinds of partnerships with things in telemedicine, then chat technologies and things like that so that we play well with others and could be part of a Lego set if you will, that all kind of works well together.

Paddy: Yeah. So, you compete in some area as your partner and others. Is that kind of the mantra?

Graham Gardner: That’s right. And you know, a lot of the deals are just understanding the boundaries. So, hey, I’m going to go up here. You’re going to do it from there. And how do we work together and serve the customer the best?

Paddy: Yeah. So, you know, you mentioned the pilot plant. Actually, some of the things you mentioned a little bit counterintuitive if I may say so because you would think that the small deals have an easier chance of entry because, you know, it’s not a big financial commitment and it’s easier for people to make that kind of commitment at least from a buyer standpoint. But what is counterintuitive also is that larger deals get more attention and also are more likely to get to organizational buying and support to ensure the success of the program. That’s kind of a little bit counterintuitive, but it’s very insightful as well. Let’s talk about the pilot thing. You know, death by pilot, pilotitis, you know whatever flavor of that. That seems to be the pain of the startup ecosystem in healthcare. In addition to long sales cycles and all of that stuff, what is your recommendation to health systems to break through this and, there is a mutual win-win here if both parties can get together and pull out a solution, that is where there is an obvious ROI? But it doesn’t seem to be happening fast enough. So, what is your recommendation? What is your wish list, if you will, for health systems to be doing in order to accelerate the adoption of innovation?

Graham Gardner: Yeah, I know. It’s a great question and what I think a lot about Paddy. I think on the health systems side you know what I enjoy the most is where an organization really has identified its priorities. And, you know, I understand. I am sure you go to HIMSS every year. And I remember standing in that football field of vendors one year and realizing, oh, my gosh, this is what the inbox looks like for someone at these health systems. I’m population health, I’m population, pay attention to me. And so, I can understand that it’s overwhelming the inbound demand that comes in. And so, I think where organizations have clearly articulated these are the four or five initiatives. You know, this is how we’re thinking ourselves proactively about stitching something together. Those tend to be organizations that have really done the work and understand what they’re looking for and make, you know, faster, and better decisions. So, I think that’s one of the things that’s really taking a proactive view as opposed to the kind of a reactive one. But then I think when there is a priority go in on it and, you know, there’s obviously a time and we did a handful of pilots very early on, Paddy when you’re just trying to figure out the layout, design, and understand this. But the quicker than you can move to say no, look, this is something that matters to us and we’re going to invest in it, and we’re going to invest in time, we’re to invest in money. And, you know, a couple of examples for us Paddy, they’ve actually invested the money as well in terms of equity. So, you know, a couple of our health systems are actually investors and encourages as well. And yeah, that has been a really wonderful partnership. Not that we’re ever going to return a meaningful investment to a 10-billion-dollar healthcare organization. But for the individuals that are there and putting sweat equity and introducing us and caring and trying to make a successful feeling that they’ve got skin in the game and are part of our success, I think has meant a lot to them as well. So, I think if that investment loses time and money picking something and saying, look, this is something we’re going to really work hard to try to make successful because it can’t just be on the vendor. We need too much from the organization to be successful. And so, I think it’s been committed to that.

Paddy: Fantastic. Well, Graham, it’s been such a pleasure speaking with you and thank you for setting aside the time to talk to me. I’m sure my listeners are going to have a lot to chew on from all of your comments and all the very best to Kyruus, all the very best to you and your team and all success to you. Thank you again.

Graham Gardner: Thank you. I really, really enjoyed the conversation and look forward to talking more.

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

Graham is the Co-Founder and CEO of Kyruus where he has led the development and commercialization of the company’s market-leading patient access platform that now serves over 250,000 providers and 500 hospitals. Prior to Kyruus, Graham was a Venture Executive at Highland Capital Partners where he co-founded Generation Health, a genetic benefit management company that facilitates optimal utilization of genetic testing, and served as the company’s Chief Medical Officer through its acquisition by CVS Caremark.

Graham completed his clinical training in internal medicine and cardiology at Beth Israel Deaconess Medical Center and Harvard Medical School, where he also served as Chief Medical Resident. Graham completed his BA and MD degrees at Brown University and earned an MBA from Harvard Business School. He serves as an advisor to Sigma Surgical, Sensory Cloud, and the Innovation & Digital Health Accelerator at Boston Children’s Hospital.

About the host

Paddy is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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Health systems and plans are now willing to take a leap of faith for digital patient experiences

Episode #30

Podcast with Leah Sparks, CEO and Founder, Wildflower Health

"Health systems and plans are now willing to take a leap of faith for digital patient experiences"

paddy Hosted by Paddy Padmanabhan

In this episode, Leah Sparks discusses how she founded Wildflower Health in 2012 as a digital health platform to help women in their pregnancies, after experiencing the difficulties of navigating the healthcare system during her first pregnancy.

Leah believes that digital adoption in healthcare often needs to start with simple use cases with near term returns (the short story). Although technology risks are high in healthcare, Leah encourages health systems to remain focused on the long story of needing to transform healthcare by investing in the right opportunities to create a healthcare experience that is personalized for consumers.

Wildflower Health has raised venture capital from leading health systems such as Providence Health and is considered a leading “FemTech” startup. Leah points out that while women are primary users of her platform, they are also the Chief Health Officers of their homes and influence 80% of all healthcare decisions for the entire population.

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, everyone, and welcome back to my podcast. It is my great privilege and honor to have as a special guest today Leah Sparks, CEO, and co-founder of Wildflower Health. Leah, thank you for joining us and welcome to the show.

Leah: It’s great to be here. Thank you.

Paddy: Very good. So, Leah, for the benefit of our listeners, tell us briefly about Wildflower health, the company, its evolution. What got you started on this? Maybe a little bit about your background as well.

Leah: Yes, sure. I started this company about 7 years ago when I was pregnant with my first child, at that time I had worked in healthcare for about 10 years. I had started my career at McKesson and then worked for a startup that was sold to a big PBM. Although I knew the healthcare system from the business side, but I never had to navigate it first hand till the time my husband and I decided to start a family. And I was appalled at how difficult it was as an actual healthcare consumer. Every encounter that I had outside of those directly with the clinicians such as navigating my health benefits, determining which hospitals were covered, where to deliver, navigating my high risks during pregnancy; it was all fraught with a very low tech transactional, not consumer-friendly experience. And I contrasted that with what I was experiencing as a pregnant woman consumer shopping for strollers and registering for my baby shower. I thought that if we could bridge this gap, we could not only enhance the experience of healthcare but also move the needle on quality and outcomes. Since as you know, maternal health is not as good as it should be, it is just like most other categories of health in the United States compared to our peer countries. So that was the original inspiration. However, I always knew that we didn’t want to just start and stop with pregnancy, although our initial focus was pregnancy. Over the years we have found that it is more than just starting a family. People enter the healthcare system and become engaged with it when they start a family. And we have begun to focus on the Chief Health Office of the home, who could be anyone in the family but is usually a woman according to our data. We use our technology to help her navigate healthcare, not just during pregnancy, but across a variety of ages and stages in a way that is deeply connected to the health care system. So, it is not a direct to consumer experience. It is a healthcare integrated experience using technology to make healthcare better and move the needle on outcomes. We can certainly share more about how we do that.

Paddy: Thank you for that background. Now, your company would be what we term today as a FemTech company, if I am not mistaken. Now your background and what led you to start the company is very typical of a lot of entrepreneurs that I talk to who see a need that comes out of a personal experience of some kind. Did you also see this to be a marketplace need and if not, what marketplace need were you’re trying to address with this idea?

Leah: Yes. And I will just say a word about FemTech, which is the term in vogue right now for women’s health technology companies. I would say that women are the primary users of our platform. Since women are making 80 percent of the healthcare decisions, they are influencing the whole population. It is not just about women, it is a cascading impact on a range of people and almost like a different way to think about population health. But to get to your question about market place need today, I think it is about engaging women as the Chief Health Officer of the home. Our health system clients particularly, who see this first hand in their patient interactions completely get that. But, like you talk about in all your podcasts, how do we get digital adoption? In the beginning, we focused on a very narrow use case that we knew could get adoption in the healthcare system because it was so simple. Often this is a theme in digital transformation when one starts from simple use cases and grows from there. In the beginning, seven years ago, our focused use case was helping health plans like the payers, whether it is Medicaid, commercial payers or employers to quickly identify and intervene in high risk pregnancies, to move the needle on medical costs, that would have otherwise costed thousands of dollars. Then we proved that we could do that by using a digital solution to engage women every day, identify risks faster, get them the right care with their OB or with a nurse or a care manager. We reduced rates of preterm birth and NICU admissions. So, a very simple use case could get us a simple one-year ROI that helped us to grow from there. While it is important to have the aspirational vision of engaging women as the Chief Health Officer of the home and having a different way to engage your consumers and population, but also having some simple use cases that can help get you started with often, skeptical healthcare purchasers.

Paddy: Right. So, who are your primary customers today? Who do you work with is mostly health plans, health systems, or a combination of both? Where do you see the response being the most positive and encouraging for your solution?

Leah: It’s a great question. In the first three or four years of the company, it was exclusively health plans, both Medicaid and commercial. And then a few years ago, we started getting interest from health systems, especially as we extended our model beyond maternity into a broad range of women’s health and family health. The health systems were interested, not just because they wanted to have a great experience for maternity, but because they wanted to have lifetime loyalty with their patients. Today we work with 20 large health plans. Our contracts cover over 50 million covered lives. We work with a lot of health systems that encompass 130 hospitals and their affiliated outpatient practices. Today about 60 percent of our customer base is payers and 40 percent is providers. What is interesting about this is that there are synergies between the two, because women or families don’t want to navigate health plans separately from their providers. On our technology platform, we bring the two together so that a woman in Seattle can seamlessly go to her OB and get access to an application that can help her navigate her delivery, pull in her health benefits and other resources. Those are powerful use cases which make us excited that we have been able to straddle these two historic silos and help them work better together.

Paddy: Just one more question on the split between the health plan and the provider side of your business. Did one naturally come about as a fallout of the other? In other words, did your relationships with health plans kind of naturally lead you to the providers through those health plan relationships or did it develop organically and independently?

Leah: It was organic and independent. It was more about the product capabilities. Our first client was Dignity Health who cold called us and was interested in our product after surveying the market and found us the best fit for what they were trying to do. So, it was really organic. Over time, particularly in the past 18 months, our clients, both health plans and providers have become interested in how they work together on our platform. It has been an interesting evolution.

Paddy: That’s great. First, congratulations on all the progress that you’ve made in a relatively short time. And of course, it’s a fast-moving marketplace and there are a lot of companies out there in the digital health space broadly speaking. So, you know, in this one moment of the proliferation of digital health programs and interventions, how do you actually build a business case? How do your customers decide which ones have merit? In other words, how do you actually go about establishing that business case with your clients? Who pays?

Leah: The health plans and the health systems license our software. It is a software-as-a-service business model where they pay for the licenses to access. I do think that the risks in healthcare are high. It is hard to experiment on things that do not have an obvious ROI. One of my board members, Aaron Martin from Providence St. Joseph Health had a great comment in our board meetings that for digital health companies to be successful they need to have a short story and a long story. The short story needs to be about how you can save or make money using a solution in 12 months or less. The long story then can be more aspirational and strategic about how are you going to survive in healthcare in the future? Our short story has been successful on the payer side by focusing on the opportunity to reduce costs in maternity. About 25% of the dollars spent on maternity care are costs due to complications, 70% of which could be prevented or mitigated or lowered in some way. We have some nice case studies with clients saving up to 40 thousand dollars per high risk woman who uses our platform, which is very compelling and helps tell an obvious business case. On the health system side, they think about this as a lifetime loyalty family health program. Over a dozen health systems have shown that their patients have a higher return rate to their system when using our platform. There is a higher rate of return visits, from pediatrics to adult health or even tracking family members when added to the platform, that are bringing the health system a short-term ROI of the product. In both cases, payer clients and provider clients, there is still a long story of the need to transform engagement with their target consumers, members, patients and how they are going to be relevant in the future of healthcare.

Paddy: Right. And Aaron Martin, whom you mentioned earlier on, has also been on my podcast. And I do recall this comment that he made about the short story and the long story. In fact, a related comment that comes to mind also is one of Mike McSherry of Xealth, which is also Providence Ventures Portfolio, a company he mentioned that for digital health solutions to be successful in today’s marketplace, they have to be “doctor prescribed”. In other words, you know, you can’t go directly to a consumer and expect them to adopt a solution which is not tried and tested or proven or recommended or evidence-based or any of that unless the doctor prescribes it views. So, I agree with that. Has that been your experience as well?

Leah: I agree. That is ideal but not always possible. It is hard for health plans to get all their physicians to prescribe solutions to their members. We have partnered with Xealth for this. I completely agree and our company is focused on getting integrated with the clinician and physician workflows to make our technology available there through partners like Xealth and in other ways. There have been several companies trying to get into healthcare with their directly consumer brands, and that has been a struggle as well. We have done a lot of research on women in particular, who tell us that they want plain digital health technologies that are truly connected to healthcare through a channel and brand that they can trust. And they don’t necessarily trust all the array of consumer health brands out there. But if their clinician, doctor or health plan tells them something and sends it under their brand, they have a different level of trust and expectation from that technology. I think it is critically important, but a huge challenge given that many outpatient practices are trying hard to survive in the current environment. And now they are supposed to be seamlessly recommending technology to their patients, so it is a challenge. 

Paddy: Right, and you mentioned trust and I think importance of trust cannot be overstated in the context of healthcare because the relationship between the doctor and her patient is a very special one. My understanding, again, we’ve seen the data in a lot of digital health companies that go back a few years, started out with a B2C model and didn’t really work. And a lot of them are pivoted to B2B models on healthcare is more likely B2C, some would say. And part of that is because the trust factor is not something that you can simply bypass and go directly to the consumer. And digital health interventions at the end of the day are complementary to trust and the relationship between trained and experienced and qualified physician and the patient or the health care consumers. Now when you look at your own journey, what have been the biggest challenges to adoption and growth for your own solution?

Leah: Well, I think it is the healthcare system, even when you have a pretty open and short ROI like we have. But even when you build a good base of clients like we now have, it is still slow. People are slow to make decisions since the stakes are really high. There are a lot of security requirements. It is a sluggish industry. There are a lot of reasons why some of this is acceptable because it is risky to introduce new technology to patients and clinicians. Some of the sluggishness is the fact that we have very large institutions making decisions, and sometimes which is an unnecessary bureaucracy. These are challenges that every single digital health company will face, except for the few that may be trying to go to consumers directly who again have a different set of challenges to face. We were on the first wave of digital health startups and have now matured as a company but one thing that has changed in the last seven years since I started is that healthcare systems and plans have become more willing to take a leap of faith. They feel the pressure even more today than they did seven years ago to embrace digital, especially great digital experiences for the patient. I do see a little bit more risk taking and willingness to experiment than I saw seven years ago. It is hard for me to quantify that, but I sense it and see it in the meetings that we have.

Paddy: You know, I will share a little bit of research that my firm did. We kind of have a maturity model for digital health adoption and digital transformation, if you will, among health systems. A vast majority of health systems are still kind of focused on their electronic health records systems and whatever they can get out of it before they go out and do something more innovative. But there’s a lot of health systems at the other end of the spectrum, the leading health systems. I agree with you. They are setting aside budgets. They are experimenting and, in many cases, making investments in some of the promising startups and getting invested in the success of these, which I think is really encouraging and to a point with all these long sales cycles and so on. You do need that support so that you can sustain and continue to grow while you build out your footprint. In that context, I want to ask you, Leah, where do you see the big electronic health record systems, which kind of dominate the marketplace as far as providers are concerned. And the big tech firms you know the Microsoft, the Googles of the world, where do you see them relative to your own success? Do you rely on them? Do you compete with them? Is it both? Can you talk a little bit about where you fit in the broad scheme of things?

Leah: Yeah, we do integrate our solutions with the EHRs, we pull out data. We are beginning to take data and show it on top of the EHR to like OB before our first appointment. The EHR is incredibly important. They are like scaffolding for our future digital transformation for healthcare. I would caution thinking of EHRs as consumer engagement. It is not consumer engagement. They have done well and is an amazing transactional infrastructure. But there still needs to be a consumer layer for the health care system that puts it in context. If you look at the Wildflower apps, they look more like Instagram or Facebook than a patient portal. They have articles and images and you can scroll through them and they are personalized based on reading variables in EHR. You don’t have to go look and see, “oh, I had this test result. What does it mean?” It can be pushed to you and say, “Hey, you had a positive gestational diabetes test result. We’re going to start sending in reminders that aligns to your provider’s care plan to check your blood glucose every day”. So, it’s translating it and making it personal for the user, which is a very different and important use case than the EHRs offer. I think the challenge for our business is not competing with the EHRs. It is just the distraction within health systems who are spending so much time trying to get that right, which I understand they often need to do first, they can’t get to the last mile, which I would say is putting a consumer layer on top of it. As it relates to the technology companies, I think that they’re all trying to figure out what their big play is in healthcare. And of course, they’ve been doing this for years. I remember Microsoft HealthVault, which has now been sunset in Google Health. And I think they’re still figuring out the model. They’re probably closer now than they used to be. We would certainly love to collaborate with big tech companies. But I still see them a bit sitting on the periphery and figuring it out. And they have a lot of smart people who no doubt will figure out in force. Amazon’s making a lot of headway there. I’m hopeful that some of these innovative tech companies we have in the country, like also Apple, they will bring something really important and meaningful and transformational to the healthcare system. I think they’re well poised to do it.

Paddy: You know, you mentioned last-mile solution. I’ll actually go one step further and I see that healthcare really has a last-mile problem because there aren’t enough last-mile solutions, but there’s way more of the technology platforms, all of whom are waiting for solutions to be built on top of that, like the Wildflower Health’s of the world. And clearly, digital health companies such as yours, are differentiating yourself through better user experience. So, this whole notion of human-centered design to build out the user experience, that is something that digital health startups have really taken to heart and seem to be doing an outstanding job. Of course, you need the back-end integrations with the EHR systems to get real-time access to the data and so on. Which brings me to the other question about data really. Is your experience for your customers driven primarily through traditional data sources, or have you also figured out incremental and additional data sources that you can creatively combine with some of the traditional data sources to drive the experience? Can you talk a little bit about that?

Leah: Yeah, today our experience is driven by a combination of what the user tells us about and what we can read when it’s available from the EHR and then other data sources. So, we are currently expanding the level of data that we integrate through other partners. In an ideal state, we would be able to pull in labs and pharmacy data and claims data in addition to the EHR data when it’s available. It’s important that people understand what the EHR data is, that even where we integrate with the EHRs, not all the patients have signed up to use it. We may have had the patient authenticating to pull it in and EHR is only associated with that current provider. You can’t get if she’s a brand-new patient, without an active health history. So, if you’re really going to use healthcare data, you’ve got to work with a variety of sources. Don’t underestimate the power of user data. The data we can get from trackers, from what women are clicking and tapping on, what her mood is in other things like that, you cannot get any conventional traditional healthcare data source. And so, we really believe to truly have a personalized consumer experience. It’s a combination of what we can read when it’s available in the healthcare system and what she’s telling us either directly because she’s answering a question in our device or tracking something or just by what we can detect, what images, what she likes the most. What article does she read? Which article does she click? And that combination, we think, is what true personalization looks like in healthcare. And we’re certainly not there yet. But that’s the journey we are on at Wildflower Health.

Paddy: That’s a fascinating story. Well, what would you like to see? I guess this is my last question for you. What would you like to see from healthcare organizations to accelerate the adoption of digital health innovation? You’ve talked about the sales cycle, and I don’t know how much anyone can do about that, but what would you really like to know? What’s your top one or two things on your wish list, if you will?

Leah: Oh, gosh, it’s a great question. I think the number one thing on my wish list would be for my clients and the people who work with Wildflower, I have so much respect for them. They put their necks out in their organization to work with a young, innovative company. And it’s not easy to do that. I’ve been in their shoes and I’ve been a company, so I really applaud that. And I completely understand that you have to fulfill what Aaron Martin calls that short story, that one-year ROI. But I would really encourage the healthcare system as a whole, not to lose sight of that long story. Where are we going? What is the opportunity here? What does an amazing health care experience look like? That is not siloed. That’s not transactional and doesn’t make me feel like I’m just a cog in the wheel. That’s personalized. That’s as good as what I experience when I go on Pinterest. They know exactly what I want to see in my feed. And to really have that vision as an industry is something that I think we’re all missing, including, many of the startups. And it’s hard when we’re slogging today, trying to get to the next step. But I think that’s something I would really encourage as an industry to continue to really envision to accelerate this transformation.

Paddy: That’s fantastic. Well, Leah, it’s been such a pleasure speaking with you, and I greatly appreciate the time that you’ve taken to talk to us and look forward to following your company and all success to you and your team.

Leah: My pleasure. Paddy, it’s great to be here.

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

Leah Sparks, CEO & Founder of Wildflower Health, has more than 15 years of experience building innovative healthcare businesses in both venture-backed companies and Fortune 50 corporations. Leah founded Wildflower Health in 2012 while starting a family of her own and seeing firsthand the gaps in healthcare for consumers.

Prior to starting Wildflower Health, Leah led business development for a personalized medicine startup that was acquired by Medco a few years after she joined the company. She began her career in healthcare at McKesson Corporation in corporate development, where she focused on strategy and M&A. During her tenure at McKesson, she held a variety of leadership roles including spearheading the company’s entry into the oncology market.

Leah has been featured as a speaker at leading events including the National Quality Forum, Health 2.0, and the Rock Health Summit.

About the host

Paddy is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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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 is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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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 is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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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 is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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We don’t want to improve patient experience at the expense of the clinician experience

Episode #26

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

“We don’t want to improve patient experience at the expense of the clinician experience”
paddy Hosted by Paddy Padmanabhan

Nader Mherabi, CIO of NYU Langone Health talks about digital transformation and its current state in the healthcare delivery space.

At NYU Langone Health, digital transformation means taking an enterprise approach to care delivery that is integrated, smart, and intelligent. Their vision is to provide a connected digital health service that is convenient for patients and their families, close to where they stay or work. The health system sees technology and digital as a great enabler and strategic asset to propel the organization forward in its mission.

Nader also believes that making the foundational technology work is critical for enabling the organization to build the digital capabilities of 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 for today, Nader Mherabi, CIO of NYU Langone Health in New York City. Nader, welcome to the podcast.

Nader: Thank you for having me.

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

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

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

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

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

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

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

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

Paddy: That’s well said.

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

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

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

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

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

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

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

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

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

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

Nader: Sure.

Paddy: Okay. Here we go, Cloud.

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

Paddy: Okay. Next one, voice recognition.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Paddy: We look forward to staying in touch.

Nader: Thank you. My pleasure.

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

Nader Mherabi, Senior Vice President and Vice Dean, Chief Information Officer, is responsible for all information technology (IT) activities for NYU Langone Health and for information technology’s development as a strategic organizational asset. He previously was Vice President for IT product solutions and Chief Technology Officer for NYU Langone, responsible for technology strategy, infrastructure engineering, networks, data centers, application architecture, systems deployment, and support across the institution. Mr. Mherabi currently leads NYU Langone Health’s digital transformation initiative, driving the integration of the institution’s workflows, revolutionizing the digital patient experience and clinical environment, and empowering the institution with big data and advanced analytics to improve care delivery and efficiency.

Mr. Mherabi has designed and implemented many large-scale, diverse systems for NYU Langone and has extensive experience in hospital clinical systems integration, research information technology, and education systems. He has developed an operational architecture for in-house application development and integration, as well as an electronic data repository, warehouse and dashboards center, research-specific infrastructure for computation and collaboration, and scores of mid-size applications for research, education, and clinical care environments.

During his more than 30 years in the information technology field, Mr. Mherabi has implemented large-scale systems for top Fortune 500 companies worldwide, such as Credit Suisse and CitiGroup, and held several prominent IT management positions including Senior Director at Mount Sinai–NYU Health, Vice President at Credit Suisse First Boston, Vice President at Citibank, and Senior Application Developer at AT&T and Aurora Consulting.

About the host

Paddy is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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If you’re a traditional CIO with a traditional mindset, you’re going to be disrupted

Episode #25

Podcast with Edward W. Marx, Chief Information Officer, Cleveland Clinic

"If you’re a traditional CIO with a traditional mindset, you’re going to be disrupted"

paddy Hosted by Paddy Padmanabhan

In this special 25th episode, Ed Marx discusses his personal experience with two major health events over the past twelve months, and how information technology played an important role in both events.
At Cleveland Clinic, where Ed is leading an enterprise digital transformation strategy, ‘digital’ means leveraging technology to produce seamless experiences. Recognizing the need to support legacy environments while advancing the enterprise digitally, he suggests that CIOs and digital leaders must be “bimodal” and be able to show progress and success despite constraints.


Digital transformation is not a solo trip; Ed stresses the importance of global partnerships, and aligning with the right partners can help achieve wonderful things.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Ed Marx: Thank you Paddy.

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

Edward Marx is Chief Information Officer at Cleveland Clinic, a $10 billion medical system that includes a main campus, 10 regional hospitals, 18 family health centers, and facilities in Florida, Nevada, Toronto, Abu Dhabi, and London. He is responsible for the development and execution of strategic planning and governance, driving optimal resource utilization, and team development and organizational support. Ultimately, he will develop leaders and leverage digital healthcare technologies to enable superior business and clinical outcomes.

Prior to joining Cleveland Clinic, Edward served as Senior Vice President/ CIO of Texas Health. In 2015, he spent over two years as Executive Vice President of the Advisory Board, providing IT leadership and strategy for New York City Health & Hospital.

Edward began his healthcare service as a janitor while in high school where his commitment to patient care began. He later served as an anesthesia technician before transitioning to the information technology field. Concurrent with his healthcare career, Edward served as an Army combat medic before becoming a combat engineer officer.

Edward is married to Simran and they have five children and three grandchildren. A member of TeamUSA Triathlon, he attempts to stay health through competitive cycling and running.

About the host

Paddy is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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Consumers are looking for convenient, price-transparent solutions to manage their healthcare.

Episode #24

Podcast with Giovanni Monti, VP, Director of Healthcare Innovation, Walgreens Boots Alliance

Consumers are looking for convenient, price-transparent solutions to manage their healthcare.
paddy Hosted by Paddy Padmanabhan

In this episode, Giovanni Monti discusses his current role and how the digital healthcare innovation group at Walgreens is focused on bringing new and sustainable innovative solutions to consumers.

Innovation at Walgreens is to have consumers manage their healthcare in a convenient and cost-effective way with great outcomes. It is all about delivering care to consumers when they want it, how they want it, and where they want it. Some eight million customers walk through a Walgreens store every day. Through their recently released Find Care app, Walgreens has started providing a range of personalized and localized healthcare services to consumers. Going well beyond the traditional e-prescription function, the app is a digital front door that delivers services from a curated set of 30 partners that can be accessed anytime anywhere with price transparency.

Giovanni’s current role at Walgreens is to focus on extending these partnerships by working with the right innovators at the right time in their product and market growth.

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 talk about how they are driving change in their organizations.

Paddy: Hello everyone and welcome back to my podcast. This is Paddy and it is my great privilege and honor to introduce my special guest today Giovanni Monti, Vice President and Director of Healthcare Innovation for Walgreens Boots Alliance. It’s very rare for me to actually do a podcast interview in person and this is one of those rare occasions. I am at the Walgreens Boots Alliance corporate headquarters in Deerfield, Illinois. Giovanni, thank you so much for joining us and welcome to the podcast.

Giovanni: Thank you Paddy. Great to be on your podcast and doing it in person.

Paddy: Very good. So, let’s get started. Tell us a little bit about your current role and the digital Healthcare Innovation Group at Walgreens.

Giovanni: Sure absolutely. So, Walgreens and Walgreens Boots Alliance in particular is basically the largest pharmacy networking in the world. And so, in my role I’m really focused on extending the relationship that customers have with their pharmacies and pharmacists from the pharmacy to overall healthcare. And to do that not just in store but where and when they want it with the view of helping the customers better manage their healthcare. We do that by sometimes developing new pharmacy services delivered in store. Other times developing a digital innovation that are then delivered in a nominal channel way and it’s really like all the innovations a great team effort not only my team that which is between Seattle, Chicago, and the U.K. But the overall company from the stores to everyone else as well as partners because through our innovations we also bring lots of partners and innovators to market.

Paddy: And we’ll cover a lot of this as we go along in the conversations. You mentioned a couple of things. Clearly your focus is to take your retail consumer relationships to an online relationship. That’s one of your focus areas and you also mentioned healthcare is all about delivering care to consumers when they want it, how they want it, and where they want it. I know that Walgreens made a big digital splash earlier this summer with your new app you want to share a little bit about the app.

Giovanni: Sure. Absolutely. So, the Walgreens app was already a very successful app that Walgreens customers are utilizing on daily basis to manage their prescriptions. And what we’ve really done is a year ago we started extending that app, as I was saying earlier, enabling consumers to manage their healthcare more broadly. And so, what we’ve launched is – Find Care – which is a new solution available on the Walgreens app and on Walgreens.com and it’s a platform enabling individuals to connect with healthcare solutions based on where they are and based on their healthcare needs. And we’ve designed it in a way that it’s totally customer centric and on Find Care then consumers would find. Of course, all the Walgreens services that we deliver but also a curated selection of partners. And these solutions deliver by these partners. Sometimes in-store other times purely digital in a very consumer friendly way. We launched it a year ago approximately and then we keep adding new partners and new solutions based on what customer needs and based on what we learned from the eight million customers that goes through Walgreens stores or digital on a daily basis.

Paddy: I will come to the partnerships in a minute. Could you tell us what was the need you perceived in the market as you started thinking about this app for the consumers.

Giovanni: Yeah absolutely. So, what is happening in healthcare, as you are covering in so many of your podcasts, is that consumers are looking for convenient solutions they want or sometimes need to be more involved in managing their healthcare costs some time are escalating. So, there was a need to connect individuals to more convenient price inspiring solutions. And we had the opportunity of doing it. Given our great footprint and daily traffic as I say in stores and digitally. And we already had a great starting point because through Walgreens we have lots of partnerships on different customer needs in different regions with different partners whether it’s you know labs, and urgent care, and primary care, or other partners. So, with Find Care, we aim to address these customer needs of a convenient transparent access to their health.

Paddy: Let’s talk about the partnerships right. The Find Care app which by the way is on my phone as well. I’m a Walgreens customer and I pick up my prescriptions using the Walgreens app and now I have Find Care which gives me a whole menu of offerings. I’m going to let you actually talk about the offerings and you mentioned a curated list of partners so tell me about the curation process. Well firstly how did you curate the services that you wanted to offer on the app and then how did you curate the partners who are going to offer it on your behalf on your digital property.

Giovanni: Yeah absolutely. So, we want to make sure that customers have access to proven reliable solutions to manage their healthcare. And we look at what the customer needs are, what the various innovations are, what is available on the market, but maybe not really utilized because of lack of direct access to consumers. And we come up with a prioritization for the Find Care development in terms of adding new services and new partners. As we identify target areas then we aim to start with the leaders in that area. And again, the starting point was really great because when we launched it, we had already 17 partners on board. Starting with who was already working with us in store maybe with co-located clinics, urgent care, online doctors from MDlife to Providence, Narcolepsy, etc. But then quickly Find Care has already become a way to based on the customer needs attract to Walgreens new partners that deliver their solutions. So for instance over the past few months we’ve announced the extension of Find Care to chronic condition management, with now Propeller available on Find Care to manage asthma and COPD or Dexcom in continuous glucose monitors. So, there is a whole stream of solution providers. There are also new care delivery models whether it’s doctor or house calls like Heal. And in the west or tele derma solutions in this case nationally. And then we also look at national versus local in a way because depending on the service and depending on the partners which is what makes sense. So we’ve also added in certain geographies where we didn’t yet have a great local offering through Find Care more partners like Houston Methodist or other national solutions as well. So that’s really the principle of how we develop the partnership on Find Care.

Paddy: And now how many partners are you right now?

Giovanni: Approximately 30 but it’s growing quickly. Yeah. So as of today, 30 but maybe.

Paddy: Maybe the next time when we speak it will be much bigger than that.

Giovanni: Some offer more than one service because they might have urgent care and telehealth through Find Care for instance.

Paddy: So is it fair to say the focus of the offerings is routine primary care but also urgent care. Are these the two main focus areas?

Giovanni: You know it goes all the way to the beauty of a platform like Find Care is that it really enables deep personalization and localization. So, we are adding services that we know will be valuable only for certain segment of our customers. But when they are there would be very valuable. So, we’ve gone all the way to. tele dermatologist I have mentioned earlier or even second opinion is already available on that on Fine Care. So clearly telehealth, urgent care, primary care is some of the focus areas, but we like any internet platforms we can manage the long tail.

Paddy: So, let me switch topics here for a minute and talk about the data that’s powering many of these applications. Now you mention you have a very strong foot traffic in your store so obviously you have a very strong understanding of your retail consumers and retail healthcare consumers. Now to build more of a healthcare relationship you probably need other data sources as well about the clinical and their claims history and so on and so forth. Can you talk a little bit about your data strategy as it relates to building out new products and engaging more with your patients?

Giovanni: Yeah absolutely. So, the way we look at it is that we are totally focused on the customers interests. Walgreens and the other Walgreens Boots Alliance companies in other countries are a very trusted and pharmacies are a very trusted counterparty or healthcare stakeholder. And so, there is a great level of trust that consumers have in interacting daily with us in store and digitally. We with Find Care continue to be totally focused on the customer’s interests. So as Fine Care evolves both from a product perspective as well as partnerships and as a deeper data strategies and opportunities are becoming possible, we prioritize and decide the entire entirely the art of the possible enabled by data centered on the customer interest.

Paddy: And I did notice that the Find Care app all the services that are offered on the app. There’s actually a price indicated as well. So I assume that it was a conscious decision on your part to list all the prices for all of the services so that consumers had price transparency when it came to your store just like they would for anything that they bought at the store even though it’s a digital health offering and that’s kind of a unique and interesting thing as well.

Giovanni: Yeah. No absolutely we believe it’s where we know from customers feedback and insight that it’s something they very much look for and we’re very focused through the Find Care platform on building the necessary transparency together with the convenient access solutions.

Paddy: So the applications like Find Care are what I refer to as digital front doors. This is like a digital storefront for consumers to come in and veil of broad range of health care services. Walgreens is not the only company that is launching these kinds of digital front doors. A lot of traditional healthcare providers as well as non-traditional healthcare providers are getting into the business and so the competitive landscape for primary care, urgent care type of services is evolving. Would you like to comment on what you see as the current state of the market as it relates to the emergence of digital front door type of offerings.

Giovanni: Yeah sure. So, it is absolutely an evolving framework in a way and with non-traditional players as well. And even I would say the traditional players are playing their role in non-traditional ways because it is possible today thanks to the evolution of a technology, data, interoperability, regulation depending on the countries et cetera to connect the customer and patient journeys in different ways. With Find Care and with the Walgreens network we are focused on enabling those new care delivery models and customer journeys without you know the unnecessary barriers between one and the other. So for instance a while ago almost a year ago we in Walgreens we launched a collaboration with Humana opening partners in primary care centers for seniors or with more recently announced one with VillageMD for primary care offering forum for adults and these collaborations. Of course, then as they go live they also go live on Find Care where there are many other evolving offerings as well. I think the principle that we must keep in mind and design to is the integrated journey where it’s possible between the various care delivery stakeholders and pharmacists and primary care and the rest which is what consumers are looking for in addition to price transparency.

Paddy: And you also have partnerships with hospitals I think Advocate Aurora is one of your partners. So, you I am assuming have a referral arrangement in place where your consumers were looking for more acute care type of services. You could refer them to one of your partners in your patient care network. Is that the intent?

Giovanni: So, it’s all built as I said earlier with customers first transparency, and choice, and consumers depending on where they are see different offers. Because in their geographies there might be certain partnerships and those will be different from other geographies like healthcare systems are across different states.

Paddy: How has the response been since. So, the app has been out there for what three months four months now?

Giovanni: The latest services yes leaner version with fewer partners and services now a year. Did the response. Look we’re really pleased with the response I would say. And what we were talking about partner so let’s continue that. We have almost doubled the number of partners and services available on Find Care in the first year which is a great sign of the interest that so many partners and healthcare innovators have in bringing through us proven healthcare innovations to market. Because again we have such a good connection credibility in daily flow of customers that we can truly help our customers partners. But also, the reaction from the stores and from customers has been very good with the colleagues in stores that I’ve learned they’ve gone through training and now have one place to go to find new solutions to recommend to consumers. Customers these stories they liked the most of a customer’s reaction is when they’re actually able to find the end to end solutions on Find Care may be in store where a colleague recommends them for a certain need to access the platform they do a consultation or access any of those services and are able to walk out of the store with their health need. So, which is pretty impressive. Whereas from a more if you on healthcare innovation and digital perspective we’re also quite happy that in less than a year we were already shortlisted as a Webby honoree which is a great start for a new digital.

Paddy: Yeah. Congratulations. Let me take a step back now you’re also the Director of Healthcare Innovation and this is clearly a very innovative new offering from Walgreens. Can you talk to us a little bit about how you define innovation? Every organization has a different definition. What is your definition of innovation? How do you define success metrics and how do you track? How do you measure success with innovation?

Giovanni: Yeah absolutely. So, I’ll repeat what I said earlier a bit because it’s really what we stand for in a way. We want to have consumers manage their healthcare in a convenient and cost-effective way and with great outcomes as much as possible. And so, for any innovations we are introducing we are very focused on that. We’re equally focused given our scale ON MAKING INNOVATIONS sustainable which then means that for all the stakeholders involved whether it’s the digital therapeutics or connected care companies bringing innovations or our networks and scaling them up etc. We want to ensure that we can serve the millions of customers and patients we have. And so, we are very focused on from the beginning designing innovations that have that level of sustainability. So again, given our scale. We also liaise a lot with the rest of the healthcare stakeholders or national healthcare systems. Because we know that when we succeed in innovations there is a profound impact on the local health care system. Just think it. I don’t know immunizations for instance a few years ago before they were available in pharmacy the landscape was totally different. And think of the profound impact it has had on care delivery. The role that we’ve had in adding these services in pharmacy. So, you know sometimes for smaller startups is easier to start because they have to worry a bit less about the implications at scale. We have the luxury of developing innovations in a group that is just in the U.S., 8 million daily customers. So, we feel that responsibility.

Paddy: Now of course Walgreens Boots is now much more than a U.S. Company it’s a global firm. And when you look at your company’s business in a global perspective and when you look at innovation pipeline and prioritizing innovation investments and taking care of customers’ needs in different global markets how do you really manage the tradeoffs and how do you really prioritize when it comes to managing let’s say consumer needs in Europe versus North America. How do you do that as an innovation group that’s responsible at an enterprise level?

Giovanni: Yeah. So, innovation happens everywhere. First of all, like in local communities with local contracting relationships with the local healthcare system and they maybe come up with a new way to deliver a healthcare service et cetera. And that’s fine. Absolutely. We can help scale some of those innovations. What we’re very focused on in my team in a way are the those innovations that are truly scalable across geographies because they build on common customer needs, common platforms et cetera. And I would say for instance the example of Fine Care is probably a good one.

Paddy: Yeah. And in addition to internal innovation do you have a formal program for looking at what’s going on out there in the marketplace. For instance, the startup ecosystem in the United States, digital health innovation ecosystems. Billions and billions in VC money that is going to fund startups that have very interesting ideas but of course they also come with a lot of risks. How do you really harness the external innovation in a way that it doesn’t put you at too much risk? But at the same time gives you the opportunity to tap into the innovation that is available. What are the tradeoffs there? How do you look at that market?

Giovanni: Yes. So, we are very active on the market with lots of different offices across my team and others are constantly speaking with the innovators. Let’s remember that innovations can come from you know startups as well as big leaders in their space. And we again are constantly speaking with innovators. At the same time, we’re very focused on the strategic priorities that we’ve identified based on our road maps and the customer needs because it’s important to work with the right innovators and at the right time to then really help them grow at scale. And sometimes it’s better to wait and touch base again after six months or a year when the product roadmap, marketing roadmap whatever is better aligned in these dialogues and relationship with innovators for instance. I would also add you know we go from having added the propeller. A great example of a relatively new company to actually having introduced services on sleep with Philips which is almost the other scale of the size continuum.

Paddy: One of my earlier guests on my podcast put it this way. They said we look first internally to see whether the solution is available somewhere in the system. If you find a need in the market and if it isn’t available, we ask ourselves can we build it. Those with the resources that we have. And if the answer is no to that then we’ll go out and look whether such a solution is available out there in the market. And they of course do one more thing which is that if they really find it interesting solution then go out and put some venture capital money into the company themselves. Do you have a V.C. fund? Do you look at companies that way?

Giovanni: We’re really focused on bringing new solutions to consumers. That’s our DNA with the network we have, the role that we have in pharmacy and our network. And sometimes innovation is available. And however, they’re not where the customers are, and we can how that happen. So that is really our focus and the way we can create value for consumers as well as for innovators that want to scale up their innovations.

Paddy: That’s where we all said. Well we’re coming up to the end of our time here. Giovanni is there any closing thoughts anything that you would like to share maybe some new innovation that you’re working on that you’d like to share with us?

Giovanni: What I would say is first of all thank you again for the opportunity of being on your podcast. And I would say just go on Walgreens.com and check out Fine Care and see whether there is an opportunity for your company and healthcare system, solution providers, digital therapeutics, whatever it is to connect with our customers in a personalized targeted way. I was mentioning earlier Phillips, it’s the latest addition to the solutions that we offer via Fine Care with their smart sleep analyzer that providers personalized recommendations. There is a there is a lot that innovators can do with Fine Care and the Walgreens scale and network. There is a rich product roadmap and partnership roadmap. And I look forward to sharing other developments maybe in the near future.

Paddy: Yeah. And we’ll be back again, and we should touch base maybe six months to a year from now and I’m sure you’ll have a lot of new updates and lot of new innovations to talk about you on. Giovanni it’s been such a pleasure speaking with you. And once again thank you for hosting me at the Walgreens Boots Alliance global headquarters here in Deerfield, Illinois. And thank you once again. We’ll be in touch.

Giovanni: Thank you. My pleasure. Thank you.

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

Giovanni leads healthcare innovation at Walgreens Boots Alliance (WBA), the first global pharmacy-led health and wellbeing enterprise. Prior to leading the healthcare innovation, Giovanni was Director of Corporate Development and M&A at WBA since 2012, with previous experience in corporate development, M&A, and management consulting.

Giovanni is a member of the Advisory Board of the Healthcare and Pharmaceutical Management Program at Columbia Business School, and holds a Degree in Economic and Social Sciences from Bocconi University, Milan, and both a Master in Business Administration (MBA) from Columbia Business School and a Master of International Affairs (MIA) from the School of International and Public Affairs, Columbia University, New York.

About the host

Paddy is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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Digital transformation is not just about digitizing and automating workflows

Episode #23

Podcast with Dr. Sylvia Romm, MD, Chief Innovation Officer, Atlantic Health System

Digital transformation is not just about digitizing and automating workflows
paddy Hosted by Paddy Padmanabhan
In this episode, Sylvia Romm discusses her role as the Chief Innovation Officer at Atlantic Health System and how her prior experience in pioneering telehealth adoption influences her views on digital transformation.

Most healthcare organizations are reactive today as opposed to being proactive. Digital transformation is off to a slow start but disruption will be here before we know it. According to Sylvia, innovation at Atlantic Health System starts with developing internal innovation and standardizing it across the health system. It also means developing external partnerships to build an innovation pipeline. However, she does not believe in investing in “shiny new things” that do not help their health system move forward.Sylvia believes that digital transformation is not simply automating or digitizing all the current workflows. It has to go beyond replacing in-person visits with one-on-one virtual visits and look at reimagining patient and caregiver experiences.

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 talk about how they are driving change in their organizations.

Paddy: Hello again and welcome back to my podcast. This is Paddy and it is my great privilege and honor to introduce my special guest today Sylvia Romm, Chief Innovation officer of the Atlantic Health System. Sylvia thank you so much for coming on our show and welcome.

Sylvia: Thank you so much Paddy. I’m really happy to be here.

Paddy: Thank you. So, let’s get started. Can you maybe just tell us a little bit about the Atlantic Health System and your current role for the benefit of our listeners.

Sylvia: Absolutely. So Atlantic Health System is the health system that’s in northern New Jersey. We are a mid-market sized health system with six hospitals and four ACOs, about 4000 physicians, and between the hospitals we have just around a thousand beds. So that gives you a sense of the size of our health system. We have really a visionary and strong leadership which is actually one of the main reasons that I came here. Our CEO is actually one of the leaders at the American Hospital Association and he’s been really great about bringing Atlantic Health System together really as a health system and thinking about ideas in a broader and more visionary way.

Paddy: I know that you came into your role recently and prior to that you were involved for several years in pioneering telehealth adoption. Do you want to talk a little bit about that and maybe give us your assessment of telehealth adoption today?

Sylvia: Yeah absolutely. I’ll sort of start a little bit back and give a little bit of my background just so your listeners understand how I think about telehealth and what angle I’m coming from. So, I’m a pediatrician by training and I was practicing as a hospitalist when I had my second child and wanted to have a little bit more flexibility in my schedule. I actually came into the telemedicine world as a physician looking to use telemedicine as a way to see patients and as a way to see patients from home. So that was a little over five years ago which doesn’t seem very long, but it is kind of an eternity in the adoption of telemedicine. And I started with a company that was just starting up doing urgent care video visits at the time. Pretty soon after that I started practicing with them and I thought as a pediatrician and as a new mom for the second time that new parents are the ideal target for telemedicine. And you have lots of questions and it’s kind of hard to leave the house. And so, I started a telemedicine company for new parents with breastfeeding support that eventually started offering nutrition support as well. After getting that going, I became a subcontractor of a much larger telemedicine company called American Well providing those clinical services to them. And then eventually came on to American Well full time. And through American well, started off in kind of a medical director role. So initially looking at clinical guidelines and quality but pretty soon thereafter really going into more of an executive role working with health systems to think about how to adopt digital technology. So, my view changed really from a user as a physician of telemedicine technology to truly finding out how digital healthcare delivery can fit into the larger ecosystem. So, when I think about that and I look at telehealth adoption there’s a really wide variety of adoption depending on which population you’re looking at both from the patient side and from the provider side. So, from the patient side you see most of the visits particularly in video visits. And this did take another step back. I’m going to be talking about telemedicine not meaning only live synchronous audio video connection. I actually like the term digital healthcare delivery more because I think that allows people to think about different technologies in the same way. But I know that most people when they talk about telemedicine, they’re talking about video visit and so I’ll try to be clear when I’m talking with one of the about one or the other, but I sometimes will use it interchangeably. But the vast number of video visits or even phone visits that are happening between patients and physicians are really urgent care style visits that are set up by health plans. The adoption by health systems of using telemedicine again the volume still tends to be third party clinical providers. That are providing video or telephone visit but you’re starting to slowly see health systems using telemedicine technology so their own physicians can see own patients. But that’s taking a lot longer to ramp up.

Paddy: That’s still in early stages. So that’s an interesting background. So now you are Chief Innovation officer at Atlantic Health System. How do you define innovation and what is your innovation model at Atlantic Health System?

Sylvia: Yeah that’s really a great question because innovation can be defined in so many different ways. So, when you look at innovation roles and innovation divisions and this is a new role at Atlantic Health System. And so, I am defining a lot of what it means to be Chief Innovation Officer at Atlantic health as we speak. When you think about innovation departments or innovation shops there are a couple of just very large buckets that you can put the shops into. One is taking internal innovation within the health system and developing it maybe standardizing it across the health system especially if you have a very large health system. You can have pockets of innovation and it doesn’t even make it to the other sections of the health system and potentially even taking some of those ideas and commercializing them and spinning them out. Another way to think about innovation is bringing in external partners. This is often done through something like a venture arm where you are seeing the innovation that is happening in the entire ecosystem and trying to bring that innovation into your health system. One to get the innovation that is happening explicitly with that company and with that partnership. But also to bring in some of those ideas and the mentality maybe for example design thinking which has been supported perhaps a little bit more in some of these external companies and just bring that type of thinking within the health system so that it helps you innovate as well. And this position is doing a little bit of both. Our health system has a group called Atlantic Health Care Advancement that has been working as an innovation pipeline to bring innovative ideas from people across the health system and it really is why swath of people that have been submitting ideas to the pipeline anywhere from specific devices that then we support to prototype and look to use internally and externally. But also, in thinking about care model delivery in certain processes. I mean it’s been really great to see people get really engaged in that and really think about how to bring innovation into their day to day. We’ve also started building out thinking about investments. The American Hospital Association for example has an investment fund that we’ve become an LP of and we are working with them to become an active LP and have really a reciprocal relationship where not only are they bringing in pipeline companies for us to look at but we’re also helping them understand which companies would be good for the fund to invest in by looking at the ones that really have clinical applicability within our health system. So, it’s definitely a give and take with learning on both sides. So, it’s exciting that I’m really getting to build up and develop both of these areas.

Paddy: So that’s really interesting. And it seems like you’ve already covered quite a few aspects of innovation models that some of the larger health systems we’ve been at this for much longer under the purview. And in some sense your innovation function seems fairly mature even though you’re the first innovation officer. Come back to a couple of those themes so literally especially on the commercialization models for internal innovation and also harnessing of external innovation. One of the questions that I get asked and I also like to ask is how do you really prioritize your innovation ideas and innovation pipeline in a way that aligns with organizational priorities even though individual initiatives may or may not be the best business cases. So how do you really do the tradeoffs and how do you ensure that the right initiatives are getting funded and nurtured and supported?

Sylvia: Yeah that’s an excellent question because when I think of innovation in general if you don’t know where you’re going with the innovation it’s like you have a vector. You need a direction because if you just have the size of a vector you can really go in any direction and you might not be moving towards where you want to be. And this is an incredibly simplistic thing that I’m about to say but I really think it’s important. One of my friends told me years ago that one of the schools that she went to had them ask themselves every day who am I. Who do I want to become and who I may become with my actions? And obviously that’s an incredibly simplistic rubric. Thinking about the words but it’s so useful when you think about these very large ideas like innovation. You have to understand what your priorities are. And every time you’re investing in something you have to take that step back even if it’s just for a moment even if it’s just beginning. But make sure you’re headed in the right direction with that decision because there are so many shiny things out there and there are many shiny things that get wonderful things done. But if they aren’t helping you become who you want to be. If they aren’t helping Atlantic become the health system that it wants to be then it’s not an innovation that we want to invest time in. You think it’s really important as well because in my role in American Well while I work with a lot of different health systems and it’s very common for organizations to be pretty reactive as opposed to proactive. So that when they’re looking for something there’s this general feeling that they need something new that they need some innovation and then kind of wait and see who approaches them with new ideas or new care models or new ways of doing things and then evaluate each of those ideas on an individual basis. And one of the things that I think is really important is to again take a step back and put the time and energy into understanding what your problems are and what you need solved. And then once you have a much clearer understanding about that then proactively go out and find the people that are trying to solve those problems and work with them to solve the problems that you want as opposed to waiting and seeing kind of who falls in your fishing net and examining each one of those individually.

Paddy: You know the observation that you just made our own research confirms that. We see a lot of health systems that are funding and launching a lot of new innovative solutions. They are kind of standalone ad hoc initiatives. They don’t really fall in line with the broad enterprise strategy and to your point being more proactive about what the enterprise should be looking at as opposed to looking at the interesting ideas that are coming into the pipeline and then funding and implementing the ones that look promising. And those are important distinction that you make there. Switching topics a little bit, you mentioned digital a little earlier on when you talked about telehealth and digital transformation is in early stages for healthcare. At the same time, there’s a lot of innovation, there’s a lot of effort that is going into helping healthcare enterprises get ready for the future. And we all agree that healthcare is a little bit behind other sectors such as retail, or banking, or hospitality for instance. So, when we talk to, in our research on in our work with health systems we hear about digital transformation being all about reimagining patient and caregiver experiences. Do you agree with that definition? First of all, and then can you may be share an example or two of innovation initiatives that really align with the digital transformation of the enterprise at Atlantic Health System?

Sylvia: Yeah. No that’s a really great question as well. So again, I’m going to be pulling a little bit more on my previous role to answer this than my current one since I’m just a few months in at Atlantic. But understanding that digital transformation is not simply automating or digitizing, all of the current workflows is really important. Because if all you think about for telemedicine for example is that you are replacing the in-person visit one-to-one with a video visit for example then you’re not going to fully understand all of the benefits that comes from having a digital transformation. In the way that I think about it that often resonates with health system leadership is around value-based care. And so, if you think of value-based care as simply a different way to pay for the same interactions that everybody was already having in the fee-for-service world then you’re never going to create good value-based care. Because a lot of the way that we practice medicine that we deliver care has been shaped by that. The fee-for-service interaction is actually not best for the patient or for the caregiver. And the same it is true for geography and the activation energy of coming in for a physical visit. A lot of what we do is based upon the idea that is difficult both for the caregiver and for the patient. And so, when you remove that it doesn’t make sense to just keep everything else the same. And then one of the examples they use for this and again coming from a pediatric background when you look at school-based medicine for example or school-based telemedicine programs. When schools are initially thinking about this it’s often because they don’t have enough money to pay for Nurses and so they have a shortage. And so, they initially think oh we can bring nurses in to replace the nurse that we have and that obviously has some benefit. But then you start to think oh well instead of a nurse maybe we can have a physician at this point because of the economies of scale and the efficiency that comes to telemedicine we can actually afford to have a physician that could maybe order and prescribe medication so that it just gives the office more flexibility. And then once you start thinking about that you could start to think about things like well maybe the kid with ADHD that needs to go and see their psychiatrist every month. Well one maybe this kid shouldn’t be missing a day of school because they’re already having problems. And you can have a psychiatrist come into the school. And then if you’re not missing school maybe really the kids should be seen for 10 minutes or five minutes once or twice a week instead of for a longer period of time once a month. And that you’re actually getting better clinical care when you do it that way. And again, that’s just one example of many. But you know I think of that as the evolution of understanding how digital technology can actually provide better care in circumstances. But it really needs to be thought of differently than just replacing what you’re doing one-on-one.

Paddy: If you mention value-based care and I want to touch on that a little bit. Now we all know that the shift from fee-for-service to value-based care is not happening as quickly as many of us would like to see. At the same time the investment in digital technologies which essentially assumes a capitated model of payment has to be justified in some ways. Part of it is justified through a strategic need so telehealth for instance you know you have to have a telehealth program because that is the way of the future whether or not you’re making money today you still have to invest in it. I see the sense I get is that a lot of health systems are making some of these investments to digitally transform them so as to reimagine their patients experience or their caregiver experience in anticipation of the day when you are going to be in the capitated model and value based care environment. Given that what is your sense, since you have come from the outside and you are relatively new to looking at it from the inside of the health system. What is your sense of where health systems are in the journey towards digitally transforming themselves?

Sylvia: Yeah. That’s very interesting because I think what you said is right there. It is so crucial to understand about every set it talks about………. [unclear]. It’s like trying to head towards value-based care but that being in direct competition with the fee-for-service model. And the health systems that have seen really moved forward as in digital transformation and you actually think that even more than I have in your role, you can say your thoughts as well. But are the ones that recognize that healthcare has to have this digital transformation and that it’s been a slow start. But before we know what it’s going to be here. And so, we might not be able to justify it and in fact it’ll probably eat into the fee-for-service revenue for the time being. But we have to do it. Otherwise there will be disruptors that will do it for us. And so, when I think of it in the retail world, I think of gosh how hard must have been to be on the leadership of some of these large retail store chains where having e-commerce as part of their model didn’t exist. And you know for a while there was this divide that you see in healthcare right now of all the old stores, all the old bricks and mortar stores and then you had the e-commerce disruptors and there wasn’t great integration between them. And so there wasn’t a good model, someone called this the other day as clicks and mortar which I think is great which some of these stores have adopted where for example you ordered the items that you want online and then you have a special spot in the store where they get picked up. It’s kind of a combination of e-commerce and the traditional retail. But a few years ago, that model didn’t exist right. Someone had to create that model. And so, your leadership of this big store you see these e-commerce shops opening up and they’re gaining market. But remember they still have a ton of market. You just see them coming and you have to make the decision. Do we change our entire model to try to compete with them or do we stay where we are and hope that something comes up between now and then that saves that? And you see large store chains you could see making both decisions and at the time I think that it was not an unreasonable business decision to say you know what. This is our model, we’re good at it, we’re going to keep it, we’re going to sit and wait and see what happens. But in the end, we know what happened. Lots of these stores closed and the only ones that are surviving are the ones that either have a completely different demographic or are incorporating e-commerce into how they work. And it’s a hard decision but I think the same thing is coming in healthcare. There are many health systems where I get the feeling that the leadership is like we just hold out a few more years until I retire. You know we’re not going to have to deal with this.

Paddy: So you know I hear this of being described as the two-canoe model. You have a leg in two canoes and you’re hoping that you’re going to be able to sail downstream without losing balance. Right. And what you’re describing as a clicks and mortar. You know I think that’s what they’re referring to as a two-canoe model. That’s fascinating. So, you know is the chief innovation officer. You necessarily have to deal with a lot of the risks that come with innovation. You are harnessing internal and external innovation. And by definition many of these ideas will never come to fruition. Some will consume resources and fail, and a small number will make it work. We all know that the digital health startup ecosystem is being fueled by billions and billions in venture capital money, but they have a high mortality rate for reasons not connected to the health system themselves but for their own business reasons or whatever it is. So, as the Chief Information Officer the risk becomes a very big part of your life. How do you look at this and what do you think health systems need to be doing in terms of either changing their mindset to embracing these kinds of risks? And at the same time also facilitating a pathway to success for the more promising ideas. I know it’s a two-part question. But hopefully that was clear.

Sylvia: Yeah. You know it’s funny. Having worked in the digital health world now for a few years. So, starting off as a physician working clinically in a health system and then moving to the digital health world for a few years, and now coming back to the health system faith. It’s been very interesting to see how different parties view the relationship between health systems and companies. And I actually posted something in LinkedIn, probably a week ago that has done such a tremendous response saying that I am retiring the word pilot and vendor. And replacing pilot with phase one which is you have you start something with a company that has a defined outcome that you are looking for and if you make that outcome there’s a trigger that moves on to phase two automatically which is some sort of scaling, and if you don’t meet that outcome then you stop. But it’s this death by pilot phenomenon that I think you hear a lot about in the digital health world that I’m really trying to tackle with that question and just the ideas behind it. And the other one is the word vendor which I think is supposed to be neutral. But I actually find it has implications around it that there is almost a master-servant relationship with that the company they’re working with is there just to serve the needs. You’re the vendor and having worked in a lot in one of these companies and you worked with a lot of other companies. They’re just really smart people obviously on both sides but also in the companies that are working on these problems that have a lot of knowledge of the area that they are working in. And I found this again being on the tech company side. I got to see these technologies being implemented in dozens of health systems. And so, I often had a very good view of the nuts and bolts of how this works. But I found it amazing how often I would offer to health system and leadership to help them think about implementation strategy. I mean how many of the leadership teams wouldn’t take me up on that offer. And now that I’m on the health system side a little bit more. I do think it’s this concept of -there’s a vendor that puts that barrier there because it makes it seem like this isn’t a back and forth relationship where we’re learning from one another. And I think that those types of relationships are really important. One to solve big problems because almost always you’re trying to sell something complicated in healthcare, very rarely that you’re trying to solve simple problems. And so, getting smart people with different experiences in the room working together is really important to get answers for this but it’s also you know as you said there’s a high mortality rate on the startup side. And so, as a health system part of the way that we can be a good partner. It’s not just you know offering a space for four people to implement but really giving that product and design feedback and helping them understand the complexity and value drivers of being in their health system and bring that tons of information that comes from having worked in such a complex environment to the company so that they get better. And in doing that in fact if you can implement and to health systems that puts you way ahead of the curve for most companies and the ability to scale and thrive.

Paddy: As someone who runs an advisory firm, I can’t tell you how much I appreciate just the thought that you want to replace the word vendor to something that suggests much more of a collaborative mindset. And I applaud you for that, and I wish the spirit behind that thought is something that spreads more because I think at the end of the day digital transformation is not going to be accomplished by any health system in a vacuum. This is going to be a sort of collaborative partnerships which are mutually reinforcing and where there are win-win outcomes and for that to happen words matter and once again I applaud you for this. So, you know we’re coming up to the end of our time here and I just wanted to ask you one question. Ultimately as Chief Innovation Officer. You are going to be tasked with certain goals and demonstrating certain results. How do you define and measure success or how do you propose to define and measure success or innovation function at the Atlantic Health System? How do you look at it?

Sylvia: And yet another really good question. So again, I am still just a few months into this position and really these first few months I’m more towards understanding these important meta questions that we were talking about earlier in our conversation. What are our strategic goals? Where are we headed? What do we have right now? And that’s the other thing being in a health system the size of Atlantic. As you said there is already a significant amount of innovation that exists and is developed. And so how do I bring that together. Where are we seeing the innovation? Who are the people that are taking the lead and still doing a lot of the groundwork assessment of what we have and generally where we want to go? And then once I’m able to do that then I’ll be able to look more closely at what success metrics are. In general, we talk about operations improvement and creating an innovative culture and environment, retaining our most innovative clinicians and staff into all of those are going to be a portion of what we look at. But we’re still I’m still creating the larger goals and then we’ll have to break that down into the success metrics as well.

Paddy: Right and I hope to have you back as a guest, maybe a year or so from now when you can maybe talk about some of the successes and how we were able to go about that process. But we look forward to that. So, you know I think you provided some really interesting perspectives by virtue of your having come from a technology provider organization and given your background as a pediatrician. So, it’s going to be really interesting times ahead of you and I wish you all the best in your new role.

Sylvia: Thank you very much. Yeah, look forward to talking to you in the coming years myself as well and comparing notes what was said here.

Paddy: Absolutely. Well once again thank you Sylvia for joining us and I appreciate your thoughts and appreciate your taking the time to talk to us. All the very best and I look forward to being in touch.

Sylvia: Thank you very much.

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

Sylvia Romm, MD, MPH, Chief Innovation Officer of Atlantic Health System is driven by a passion for transforming healthcare delivery to patients and communities. She brings her background and expertise as a clinician and an entrepreneur to her role as the Chief Innovation Officer for Atlantic Health System. Firmly believing that a patient-centered focus is vital to healthcare innovation, Dr. Romm works with Atlantic Health System’s team members and physicians to find new ways to improve access to high-quality and affordable care. She also forges relationships with local and national innovation partners and works to expand our organization’s research profile. Dr. Romm is an avid author and speaker in the areas of healthcare, technology, and health information technology (IT) policy. She has written articles for various publications, including NEJM Catalyst, Forbes, KevinMD, and the Huffington Post, and was named one of FierceHealthCare’s 8 Influential Women Reshaping Health IT. A board-certified pediatrician, Dr. Romm has served in a variety of clinical leadership roles throughout her residency and as a hospitalist.

Before joining Atlantic Health System, she was Vice President of Clinical Transformation for American Well, the largest video-based telemedicine company in the United States. In addition, she was the founder of MilkOnTap, the nation’s first telehealth company focused on the needs of nursing mothers and lactation support. Dr. Romm earned her Master of Public Health in Global Health from Harvard TH Chan School of Public Health. She holds a medical degree from the University of Arizona College of Medicine and completed her residency in pediatrics at Massachusetts General Hospital.

About the host

Paddy is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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We need to be cautious in the use of technology to prevent increase in total costs of care

Episode #22

Podcast with Dr. Karen M. Murphy, EVP and Chief Innovation Officer, Geisinger Health

"We need to be cautious in the use of technology to prevent increase in total costs of care"

paddy Hosted by Paddy Padmanabhan
In this episode, Karen Murphy discusses her role as the first Chief Innovation Officer and the Founding Director of the Steele Institute for Health Innovation at Geisinger, and how they are working towards lowering the costs and improving quality for the overall welfare of members and patients.

Innovation at Geisinger means taking a fundamentally different approach to solving a problem that has quantifiable outcomes. According to Karen, focusing on specific problems like price and quality will move the needle in a meaningful way. Currently, the innovation team at Geisinger is developing a new care model that leverages AI and machine learning, along with remote monitoring for a more holistic approach towards patients.Karen also believes intelligent bots will help decrease overall cost of care as they are more efficient. However, while adopting new technologies we need to be careful and prevent increase in the total costs of care due to technology.

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 talk about how they are driving change in their organizations.

Paddy: Hello everyone. This is Paddy and welcome back. It is my great privilege and honor to introduce my special guest today Karen Murphy, Executive Vice President and Chief Innovation Officer of Geisinger Health. Karen, welcome to the show.

Karen: Thank you Paddy and thank you for having me.

Paddy: You’re welcome. Karen as I understand it you are the Founding Director of the Steele Institute for Health Innovation for Geisinger and also, I think the first Chief Innovation Officer. Can you maybe give us a little bit of background for the benefit of our listeners and how it came about and what are the objectives of the Institute?

Karen: Sure, I’d be happy to Paddy. So, I was working as the Secretary of Health with the Commonwealth of Pennsylvania. And I met Dr. David Feinberg and I was working on an innovative payment model called the Pennsylvania Rural Health Initiative and engaged stakeholders across the Commonwealth to work on this payment and delivery model with me. So, when I met Dr. Feinberg shared with me that he had this exciting new role at Geisinger called the Chief Innovation Officer. And just a little bit about my background, I started my career as a registered nurse, I’ve been a President and CEO of a health system. Then I went into public service to the federal public service at the Center for Medicare Medicaid Innovation and then subsequently went to the state as Secretary of Health. So, I have a diverse background in understanding health care delivery plus the policy piece and really a passion for innovation. So, Dr. Feinberg invited me and said would you like to come to Geisinger and talk about the Steel Institute for Health Innovation. So, the Steel Institute for Health Innovation was created by the board of directors really in honor of a previous hospital health system CEO who is Glenn Steele and Glen needs very little introduction. But Glen was the CEO for almost close to 20 years here at Geisinger and really raised the profile in terms of the national stage for Geisinger being recognized as one of the most innovative delivery systems across the country.

Paddy: That’s really interesting. And I do want to spend a few minutes talking about some of the initiatives that you’ve got going on at the Innovation Center. But to start at a high level, for health system today what do you think are the primary competitive forces that you have to deal with and how does an Innovation Group align itself organizational object in that context?

Karen: Thanks Paddy that’s a great question. So, asking the question of a competitive environment how does an innovation team help. So, I think we are competing in all markets in both quality and price. In terms of the quality of the services we deliver the price that we deliver at is certainly under scrutiny and I really don’t think I think we’ve kind of exhausted the toolbox if you will and trying traditional methods of lowering cost and improving quality. I think we’ve made maybe marginal advances in quality but I mean not in the actual delivery of health care but also when I include quality I examined the patient experience of care, the patient’s ability to access services, the need, the way, the patient’s ability to understand what they’re paying for and what cost they’re responsible for. So, when I say we’re marginal I mean we’re marginal whereas an industry really marginal around that very complex ecosystem. So, let me define first innovation at Geisinger, so we define innovation as a fundamentally different approach to solving a problem that has quantifiable outcomes. So, innovation at Geithner means we are going to focus only on problem. We must take a fundamentally different approach to solving that problem and we must have quantifiable outcome to measure for the innovation. So, I think unless we take a fundamentally different approach to price and quality, I don’t believe that we’re going to move the needle sufficiently. So how does the innovation team attack those two very large problems. Certainly, in collaboration with the clinical enterprise and the whole team across the enterprise. But I think our goal is to spike to very specific initiatives that move the needle in a meaningful way.

Paddy: And that’s a really interesting definition for the works you do in fact the notion of fundamentally adopting a different approach to solve an existing problem is what I hear the most when others I talk to about digital health innovation and you also alluded to this today in healthcare which is access, affordability issues for consumers. Do you care to share one or two examples of how you actually rolled out innovation programs that address these challenges at Geisinger?

Karen: Sure. So, I should say Paddy too that the Steele Institute for Health started July 1st of 2018. So, we’re just celebrating our very first anniversary. So, I’ll give you a couple of examples of how we’re using fundamentally different approaches. So, you may have heard of our fresh food pharmacy where we identify food insecure type 2 diabetics and we prescribe the patient to go to the fresh food pharmacy. And when the patient goes to the fresh food pharmacy they’re provided with fresh food. And the way fresh food diet counseling actually monitoring of preventative services all circling this patient to improve the health of the type 2 diabetic. And I can tell you that we just expanded to three sites because our first site was really very successful. The patients that have engaged in the fresh food pharmacy have seen very positive results some more than you would think then even through medication. And they’ve also demonstrated positive outcomes on their health maintenance exams and some of the other health indicators that we ordinarily would coordinate with better healthier lifestyle. So, we’re really excited about that and that is a fundamentally different approach. We’re currently working on developing a new model of care for patients with chronic diseases. So just to Geisinger alone about 30 percent of our patient population has one or more chronic diseases. And as you know Paddy most of them have more than one. But this system that we’re using for chronic disease management right now is extremely labor intensive requiring a one to one intervention in most cases. So, case manager or community health worker and we look at the diseases in a very siloed fashion. So, we develop chronic disease management programs that are for cardiac, chronic disease management programs that are diabetics, chronic disease management programs for COPD. But the fact of the matter is most of these patients are all three so they could have congestive heart failure, COPD, and diabetes. So, we’re looking at developing a more holistic approach and over the next three years we’ll be developing new care model that leverages artificial intelligence and machine learning along with remote patient monitoring and patient reported outcome to number one. As I said before looking at the patient and more holistic fashion. Number two to really slow down the progression of the disease. And number three prevent disease exacerbations that would require a higher level of care such as the emergency room or hospital admission. So, there’s just a couple of examples of where we’re working really hard at lowering cost, improving quality for the overall welfare of the members and patients we serve.

Paddy: That is such a fantastic example. You know when I talk to folks very often the notion of innovation is somewhat conflated with technology and sometimes you see a lot of startups out there and I’ll come to that a little further on in our conversation. They launch solutions that are fundamentally different ways to approach a problem but there’s no validation in terms of the people process and change management aspects of it. It’s sounds like you’ve covered all of that in the fresh food pharmacy. The cold concept that you just described. I think that is just a fantastic case study. Thank you for sharing that. Now you alluded to a couple of other things when when you talked about that case study. One of them was artificial intelligence. Now we’re seeing a lot of new AI enabled solutions to hit the market. More recently I’ve seen lots of announcements about AI enabled chatbots, symptom triaging and things like that. These are not necessarily just traditional health systems there are a lot of non-traditional players also coming into the market. So, I guess switching gears here a little bit, you care to your thoughts on how health systems could be leveraging technology more to drive the primary care experience and to address emerging competition in the context.

Karen: Sure. So, I think that you know others have used Paddy you raised chatbots within the Steele Institute we have a hub for what we’re calling artificial intelligence automation. I think the use of chatbots certainly are appropriate in a couple places I think those that where we have repeated questions. I think it’s perceived by the patients that the bot does a better job in terms of efficiency and information that I think that’s appropriate. I think the other place where bots are going to be very important and are going to be those tasks that humans do repetitively that we really don’t require a human to do that. But I think we have to have our intelligence bots. So not just a robot that can keep doing the process over and over again but one that learns from the activities that they are doing and I think the part that I think is important about them is that it will help us decrease the overall cost of care because obviously the use of bot is much more efficient and those use cases are really infinite and other industries have demonstrated they’ve done that really well. I think the big part we have to remember about when we talk about artificial intelligence, machine learning in any case is one that certainly there are a whole host of ethical issues that we have to be of course cognizant of. There’s a whole host of especially in clinical medicine if we’re changing the way that we practice. So, there’s a whole, there’s certainly a side to that that we have to be very careful of. But really even and the most simplistic side like all technology there is many things the data scientist can do particularly in the predictive arena. But we need to be aware that in particular in the predictive arena that the data is usable so that we don’t increase the total cost of care. In other words, I’ll give an example highlighting people who are predictive first stroke and there are 30000 of them. Very hard to do an intervention with technology with to notify 30000 people that you don’t actually have to hire other individuals to do it. So, I just want to be I know I’m a little bit always cautious about adopting new technology that we don’t end up increasing the total cost of care as opposed going in the other way because as we began this talk it is critically important for us to decrease that total cost of care and increase the quality.

Paddy: Right. And I think you made some very good points there and we’re all aware that the FDA is now looking at how to really understand and offer some level of oversight on how artificial intelligence rhythms are deployed in the context of healthcare and what is the level of regulation that is required or not. And so, I think the debate is still ongoing, but I think you made some very good points. And just to follow up on that I wanted to ask also about the data sources right. So, for AI algorithms to work well, the more the data and the more the data sources, the better they are at accurately predicting let’s say disease progression like stroke that you mentioned. So, can you share a little bit on how are harnessing emerging data sources such as social determinants or genomics for example.

Karen: Sure. So Geisinger currently has we have about 23 years of electronic health records and unified data architecture. We also have other sources of data in that unified data architecture the social determinants of health. We’re actually not only taking in from external services but we’re looking at now not only screening for social determinants of health but also identifying community resources that we could immediately connect the patient to when we recognize what the challenge is, what the social need is.

Paddy: So, let’s talk a little bit about the fact that Geisinger there’s actually a health plan and a health system and you’re unique. And so how does your innovation model balance the need to build the health system and the health plan and prioritizing your innovation investment. How do you pick your big needle movers as an example?

Karen: So, I would say a couple of things to that. So, the first is that as I said long before I got here Geisinger is a very innovative organization. And there are many operators that I would say are truly innovating here at Geisinger. So, the innovation that occurs is not just limited to the Steele Institute. So, when we pick projects or select projects for the Steele Institute, we really try to select like I referenced before a new model of care. We really try to select those initiatives that have perhaps a larger, more far reaching, ROI in both cost and quality that will benefit more broadly the organization.

Paddy: Now switching topics here, lately there have been several announcements about you know large health systems or health plans are turning innovation programs as commercial entities. In other words, an example of that was a recent announcement by Highmark which is looking to commercialize their innovation program and offering up the data to startups and researchers to test out new solutions or products and really creating additional revenue streams. I was just curious. I know its early days yet for your innovation program but is there a long-term goal to sort of maybe try and commercialize some of this?

Karen: We definitely are exploring commercialization in the common development realm and what that really mean is if there is not currently an application on the market to solve the problem that we’re trying to solve that we would open up and invite companies to come in and work with us and we would co-develop. So there definitely is an interest there. I would say the difference Paddy is that our approach is exactly that. Here we have a problem that we want to fix and we want to work with it and this is how we’re going to work as opposed to just opening it up more broadly we just want to be sure that we’re answering for problems of the future, of the present, and the future.

Paddy: So, when we talk about innovation we’re also talking about digital transformation. You actually provided some great examples of how you’re already on that path in many ways. In the way you select projects, in the way you’re rolling out the projects. It’s of course very difficult for a single innovation group to meet the entire needs of an enterprise especially if you want to accelerate digital transformation. There’s a huge ecosystem of startups out there who could potentially help you, they’re funded by billions in VC money. But it’s also hard to determine which ones of them are validated, what’s the risk involved and so on. So, can you maybe share your thoughts on how you harness external innovation today and what do you think are some of the risks that need to be managed.

Karen: Sure. So, I think you’re absolutely right in terms of there just by definition of what they do is they’re unproven. Right. So, by being a startup early in business not a lot of experience all the risk that comes along with that is inherent to that selection. And I would say quite honestly that we’ve experienced both really good experiences and had some experiences that didn’t work out so well. And I would have to say that they didn’t work out the failures were just as important as the successes because we learned. In this new territory of startups we learned what we would do differently and if you call me in a year I’ll probably say the same thing that we worked with a lot of startups that we had some successes and failures because I think that’s the nature of the work.

Paddy: Well I think we are coming up to the end of our time here and I want to ask you about you know you’ve now you’ve been in both public health and in private institutions and most recently before you came to Geisinger as you mentioned. You were Secretary of health for the State of Pennsylvania. How does a public health experience inform and influence your work at a private institution and what is your advice for someone looking to make the transition either into public health or into private sector?

Karen: So I have said this before Paddy when I was interviewed that I spent most of my career in the private sector but just had the magnificent opportunity to work in both the federal and state government. And I always say that I wish I’d found public service much sooner in my career what I would have done is moved in and out of public service and private sector because I think the best public servant is really one that is in touch with the private sector and understand how the private sector operates. But at the same time understands what it is to have the denominator be the federal, or the population of United States, or the population the state you are serving. So, I would advise anyone that had the opportunity to work in either federal or state government or any public health initiatives for really go for it because it’s a tremendous experience and it’s very much unlike the private sector.

Paddy: That’s great. That’s wonderful. So, we are at the end of our time. Any final thoughts before we conclude the podcast Karen. 

Karen: No thanks very much for having me and I really enjoyed talking to you Paddy.

Paddy: Thank you much.

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. Karen Murphy is Executive Vice President, Chief Innovation Officer and Founding Director of the Steele Institute for Health Innovation at Geisinger.

Dr. Murphy has worked to improve and transform healthcare delivery throughout her career in both the public and private sectors. Before joining Geisinger, she served as Pennsylvania’ Secretary of Health addressing the most significant health issues facing the state, including the opioid epidemic. Prior to her role as secretary, Dr. Murphy served as the Director of the State Innovation Models Initiative at the Centers for Medicare and Medicaid Services leading a $990 million CMS investment designed to accelerate healthcare innovation across the United States. She previously served as President and Chief Executive Officer of the Moses Taylor Health Care System in Scranton, and as Founder and Chief Executive Officer of Physicians Health Alliance, Inc., an integrated medical group practice within Moses Taylor.

Dr. Murphy earned her Doctor Of Philosophy in Business Administration from the Temple University Fox School of Business. She holds a Master of Business Administration from Marywood University, a Bachelor of Science in Liberal Arts from the University of Scranton, and a Diploma in Nursing from the Scranton State Hospital School of Nursing.


An author and national speaker on health policy and innovation, Dr. Murphy also serves as a Clinical Faculty Member at Geisinger Commonwealth School of Medicine and as an Associate Faculty member in the Department of Health Policy and Management at Johns Hopkins Bloomberg School of Public Health.

About the host

Paddy is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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We’re trying to fundamentally drive an improved healthcare model in the market

Episode #21

Podcast with Thomas J. Grote, Chief Executive Officer, Banner|Aetna

We’re trying to fundamentally drive an improved healthcare model in the market
paddy Hosted by Paddy Padmanabhan

In this episode, Tom Grote discusses how Aetna and Banner Health’s relationship evolved from an ACO into a new commercial joint venture – Banner|Aetna – and how with a shared vision they are improving the primary care model to transform the healthcare market in Arizona.


The collaboration between a leading regional health and a national health insurer in a 50:50 joint venture helps develop and deploy new technology solutions to improve healthcare outcomes while focusing on keeping costs low. Tom believes that joint ventures such as Banner|Aetna can also accelerate the shift from the fee-for-service model to value-based care. He discusses the incremental benefits of Aetna merging with CVS, their approach to strategic technology partnerships, and sharing of best practices among JVs of Aetna with other health systems.

Tom advises ACO leaders and Chief Population Health Officers to focus on relationships and try to align with partners who share a common vision and believe there is a better way to transform the whole healthcare system.

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. Talk about how they are driving change in their organizations.

Paddy: Hello again everyone. Welcome back to my podcast. This is Paddy and it is my great privilege and honor to have as my special guest today Tom Grote, Chief Executive Officer of Banner|Aetna which is a joint venture between Banner health in Arizona and Aetna Insurance. Tom welcome to the show.

Tom: Thanks very much. Glad to be on.

Paddy: Thank you. Just to get us started off here Tom. Can you tell us a little bit about how the JV came about a little bit of the history of the Banner|Aetna relationship?

Tom: Sure. Banner Health and Aetna had an ACO arrangement, Accountable Care Organizations relationship for five years. And it was relatively successful and had been able to grow membership together, drive down costs for the members, and improve quality. But there were seemed to be so much more that can be done on trying to improve the healthcare delivery system in terms of the care management approach and the member experience. And you know I think collectively we both felt that the current arrangement did not give us the significant opportunities to really impact that delivery model. So, we had a shared vision about trying to come together and trying to transform healthcare in the market. The joint venture presents some pretty unique opportunities, while an ACO relationship provides incentives for improving efficiency and quality. It doesn’t necessarily allow you to do traumatic changes to the way healthcare is delivered. And we felt that the joint venture platform provided that appropriate structure. The key being that we own the insurance company together. So, we’ve formed a new insurance company owned half by Banner and half by Aetna which creates full alignment and the financial incentives of the two organizations which is really addressing one of the key ongoing issues in healthcare delivery. And working together it gives us an opportunity to be more bold about how we try to change healthcare and the care management model. You know one of the things we do as we turn over utilization management responsibilities to Banner health. Under normal arrangement you know people would not understand that concept because it would look like the fox watching the hen house. But as a joint owner of the insurance company founders want to do what’s in the best interest of our members and delivering quality and efficient care. So, it enables us to move initiatives forward like getting care decisions closer to the delivery of the care and allow for more significant changes in the way we deliver healthcare. So that’s a key aspect of why that joint venture was formed and the key advantages of it. Another area is in just technology and innovation. Together working with a delivery system and the insurance companies we can develop new solutions and new approaches you know relatively quicker, actually quicker than probably both of our parent organizations. So, it provides a really unique platform to try new approaches to care delivery and member experience approaches for the people here in Arizona. So that was the foundation for why we ended up evolving our previous relationship from the accountable care organization into a joint venture.

Paddy: And we will explore some aspects of how you’re using technology, data, analytics, and innovation as we go through this conversation. Just to round out one quick question on the

structure of the JV itself. Aetna is a part of CVS, so is it fair to say that now the joint venture is 50 percent owned by CVS and the other 50 percent is by Banner health?

Tom: Yes, that would be accurate. Yeah, we’re still Banner|Aetna. But that’s true as the parent organization, CVS is the half owner of the company.

Paddy: Does anything change for the JV and its mission as a result of that?

Tom: I think there are opportunities with the CVS assets in Arizona to integrate those into our care delivery model and provide additional access points and opportunities for us to better manage our members and their product additions together. So, there will be many clinics and eventually health hubs in the markets that are very accessible to our members and they’ll provide additional access points to our members. I think the key with this though is that it’s a connected experience and CVS just becomes part of our healthcare delivery ecosystem here in the markets. So, the encounters are all captured, the data is shared and we’re able to coordinate that overall member experience.

Paddy: Thank you for that. That’s very helpful. So, Banner|Aetna’s mission is to provide superior quality at lower cost. And I imagine that what it essentially means is managing healthcare at a population level. So, what metrics do you typically track in pursuit of your mission. And how do you benchmark performance against your peer group?

Tom: We typically start with best practices from around the country but then you have to adjust for local market nuances. Arizona is actually a lower cost, lower utilization state relative to some of the other states. So, in that regard you have to adjust downward or upward on some of the goals that you set for the joint venture. But we monitor the performance of the joint venture on a monthly basis against the established benchmarks that we put forth and collectively meet with Banner on the monthly basis to review how our performance is tracking both from an efficiency and quality perspective and then implement programs around initiatives that we want to drive improvements in either our quality standards or in the efficiency and the way we deliver care. So, I think it’s one of the unique things about the joint venture is that we are coming up with solutions together to challenges that we see or opportunities that we see to improve the way we can deliver care on behalf of our members.

Paddy: So, in this podcast we talk a lot about digital health. The use of data analytics and emerging technologies. Can you maybe share with us what kind of technologies you alluded to how you’re using technology to drive improved healthcare outcomes in an improved patient experience? Can you maybe give us some examples and talk to us a little bit about how you’re using technology to drive your mission?

Tom: Absolutely. We just introduced an exciting new virtual care platform for our members as of July of this year. We had evaluated the historical approaches and did not find them to be driving the kind of utilization and member satisfaction that we would expect out of a virtual care solution. So we went to market and evaluated 15 different companies in the virtual care space and found this organization called 98Point6 that delivers an incredibly convenient and low cost approach to primary care and they leverage a text-based system that leverages artificial intelligence upfront to gather information and then a board certified doctor comes on the back end to develop a treatment plan, order prescriptions, order labs whatever is needed to help support the member’s health. And the amazing thing about this is that the structure utilizing that technology enables

them to deliver it at a very affordable basis. And so, for our members it’s no cost to access this primary care physician service that they’re in a PPO and it’s only five dollars that they’re in a HSA. So, we are extremely excited about this new offering and it provides incredible convenience at very affordable rates. So that’s the kind of thing that we stood up in less than nine months that would take a much larger organization much longer to deliver. You know another example is you know we do try to leverage capabilities of our parent organizations. And so, there is the Aetna Attain app that was jointly developed with Apple and Aetna to deliver a new Apple watch app that’s more than just tracking physical activity. It’s looking at the health history of the members, understanding the members, understanding their overall health goals. Not just about activity but about sleeping better, or eating better, and providing incentives to members to improve on those areas that the member wants to be most focused in on and reward them for those capabilities. So those are two examples of where we are implementing technology to improve the member experience or improve the health status of our members.

Paddy: Those are actually great examples of what we would call digital health solutions. It seems to me that if I look at what’s going on in the marketplace there is a lot of activity in the whole primary care experience space with both traditional and non-traditional players in healthcare coming up with chatbot enabled symptom triaging or just you know mobile enabled healthcare services and so on and so forth. It seems to me like the activity level in this space is very high and it seems that it’s all eventually going to help healthcare consumer gain better and quicker access to care at a time of their choosing and possibly at a very affordable price as well. Do you agree with that assessment Tom?

Tom: Yeah, I agree with that 100 percent. And I think you know going back to CVS. We’re now in a situation that you know our members can access care at low cost through the virtual care solution with 98Point6. They can go to a mini clinic at CVS or go to a primary care physician whatever is most convenient to them and we just want to provide as many convenient and affordable access points as we can on behalf of our members. Because you know members want to access care differently and especially when you look at the millennials and their heavy use of their phones for accessing most services.

Paddy [00:11:02] So one important aspect of enabling these digital health solutions is obviously the data and the analytics. I mean you referred to that a couple of times. You know you’ve now got access to the Aetna insurance claim data and member data, you have access to the local population’s health history through the Banner health relationship and possibly more through the CVS connections now as well. Can you talk about how you’re able to leverage the combined power and potential of data from these multiple sources about your specific member population and also what kind of guard rails do you need to have in place when you’re doing that?

Tom: Yes. So, you know connecting all those data points is obviously incredibly important. And so, we actually engaged with IBM Watson to help develop a joint database so it’s pulling in information from the claims, the lab work, the pharmacy data and combining it with the clinical information that Banner is providing. And I guess the key there is merging the records, so you make sure they’re consistent records of the same person so that you get a more comprehensive view of your members. And ultimately, we haven’t deployed it yet but we will also be layering on top of that social determinant information so that we can better connect and identify with our members. And so, I think the key with that is now taking this information that’s going to be more real time than looking at just claims data so that we can better manage the population going forward. And so that’s the focus of this relationship with IBM Watson is providing that

comprehensive more real time database so that we have a better view of our full members information. As you said you know especially when we’re done with health information you know the guard rails and the protections are really important and working between IBM, Aetna, and Banner who are all heavily vested and member protections all the appropriate guardrails are in place and then only those that need to see the data have access to it.

Paddy: Talking specifically about your population which is in a specific part of Arizona. Are there any population level aspects that you need to consider when trying to promote the use of digital health like demographic difference? You mentioned millennials for instance. Is your population skewed in one way or other to a certain kind of demographic that you have to take into consideration? I’m curious because digital adoption rates vary from state to state from region to region and demographics has a lot to do with whether your population is even going to use those tools.

Tom: Right. Yeah, I think generally we are focused on commercial populations. And so, I would say that we have a very good cross-section of the population of Arizona. I think the unique aspect of Arizona is that about 30 percent of the population is Hispanic. And from that perspective there’s a higher prevalence of diabetes in that population. And so, you know one of the things that we’re doing is recognizing the makeup of the population of the state is working closely with Banner to develop a market leading diabetes program. And that is in development. So, there’s a lot of work to develop on that but it’s responding to that population and making sure that we are doing what we can to improve the whole health of the population here in Arizona.

Paddy: Banner|Aetna is not the only JV that Aetna has. You’ve got multiple JVs. When I looked it up you have one with Sutter health, with Allina Health and a couple of others as well. Do you get the opportunity to share best practices, learn from what they’re doing especially around things like innovation and so on? Can you tell us a little bit about that?

Tom: Yes I think it’s really important in each of these JVs have different initiatives that they’re pursuing and it’s you know it’s locally based which is how healthcare should be managed. But we have a JV operations team at Aetna that helps to support improvements to the member experience and support operations across all five JVs. So, they are a single entity that is able to see initiatives going across the JVs and recommend opportunities to bring forth new initiatives to the other joint ventures. Our C-suites teams have frequent calls with one another, and we talk a lot about what we’re working on, what are the key initiatives are and so forth. And to date we’ve had a number of different initiatives that have been shared by multiple joint ventures. So, we recently introduced a new member welcome kit which number of the JVs implemented. We’re putting in a new IVR enhanced persona and 98Point6 is another example of initiatives that are being deployed by multiple joint ventures. So, we’re constantly trying to communicate with one another about different programs initiatives that are going on to see if there are things that we would like to deploy as well. And a lot of our focus is on that member experience. What is it we can do to streamline that process for the members as they go trying to access healthcare.

Paddy: So the focus is overwhelmingly on the member experience it sounds like.

Tom: Yeah, it’s the biggest challenge in our industry. We have both sides of the equation when you have the delivery system and the insurance company working together it provides the best platform to try to really come up with a solution that can change that and improve upon going forward.

Paddy: Now that’s a perfect segue to what I was also asking next which is kind of the flip side of the coin in some ways and this might sound a little provocative or controversial but payers and providers are historically not collaborated as much as one might expect. Based on your experience and that you’ve been a part of this JV and you’re working very closely with the provider. What are some of best practices? What does it take to make a JV like this work now?

Tom: The true shared vision is absolutely critical that the delivery system understand that fee-for-service is not here for the long term and that the ability to manage populations is going to be what the future holds is a critical aspect upfront because as you go through that transformation from just value-based care and to owning an insurance company you are taking a more drastic movement away from fee-for-service and more focused on population health. So, the organizations really have to be committed to believing in this new model and take senior management leadership of the two organizations to really push through their organization to help support initiatives within the respective companies to support the joint ventures. There’s so much historical friction between the delivery system in the insurance companies that it’s really important that senior management intervenes and says you know we have to find ways to change the way we work together to improve it for our members. And you know in many regards you have to ask people to go away from their standard metrics and their overalls to rethink how we should interface with one another. And it’s not an easy process sometimes because somebody there is an accounts receivable area you know has a specific goal they’re trying to achieve and you know and they’re very focused on that instead of thinking well maybe if we changed the way we set up our contracts we could eliminate all this behind the scenes work and so forth. So, it’s really important that the two organizations are constantly reinforcing what the JVs are trying to accomplish and that you know it’s going to be critical but think outside the box to come up with new and better ways to transform that healthcare delivery process.

Paddy: That’s well said. Now you mentioned fee-for-service. All indications are that there is a shift that is taking place from fee-for-service to some kind of accountable care model. At the same time the research and the studies also show that this shift is not as quick as some of us might want it to be. I read somewhere that something about 25 cents on the dollar on every healthcare dollar goes through some kind of an alternate payment model. Now whether that number is accurate or gives us a sense of the order of magnitude. Do you care to comment on where we are in that continuum and what do you think it will take to accelerate the shift towards value-based care?

Tom: Yeah, I do think that the joint ventures accelerate that process because it is more than what we’re paying the underlying piece. Under this arrangement on our fully insured business if collectively Banner|Aetna with support of Banner and Aetna are able to control the utilization and deliver more efficient healthcare on behalf of our members which is going to remove people from the hospitals, put them into lower cost settings, and about removing or reducing readmission rates and so forth. Those are shifts to the delivery system. But when you’re in the joint venture together and you are able to create those improved efficiencies. Yes, it is taking revenue out of the health system. But you know they have an opportunity to recover a portion of that through the insurance company now and sharing in the earnings of the insurance company. And so, it does change that perspective. It really is about total cost of care and it’s really about how do we solve this together. I think the joint ventures provide this unique opportunity to really escalate this process and it’s not at this environment where you get that full alignment is this how we can move that process along faster. It is still challenging because there’s always somebody that’s looking at reduced utilization in the hospital and saying well this is impacting our immediate bottom line. But

I think it’s important to have that long-term vision that we are going to continue to move in a value-based care realm going forward.

Paddy: So, Tom we’re kind of coming up to the end of time here. I did have one question for you what advice you have for other ACO leaders and Chief Population Health Officers across healthcare based on your experience and your learning so far.

Tom: I think the key piece is having relationships with organizations that truly share the vision and are committed to it as part of their makeup because that presents the real opportunities to be creative and innovative and the way you can work together. I think our joint ventures are an example of that we are really looking at the whole delivery model how does it work, how can we partner together. The bottom line is what we’ve done historically hasn’t been successful. And we can’t keep going down the same route and if we do that, we’re not going to have improvements in healthcare delivery. And so really trying to align with like partners that believe that there is a better way to do this is critical to drive change in our healthcare system.

Paddy: So, Tom we’re kind of up to the time here. Any concluding thoughts, any final thoughts that you want to share before we conclude the podcast.

Tom: Yeah, I think that I’ve been in this business a long time. I started back in 1987. This opportunity to work with Banner and together on this joint venture has been certainly the most exciting thing that I’ve ever been involved in my career because we look at it as a real opportunity to leave our mark on this industry and find a better improved ways to deliver care on behalf of the people in Arizona. So, it’s an extremely exciting opportunity. And I think when we have the right collaboration, we train organizations to really fundamentally drive an improved healthcare model here in the market. So, it’s definitely a thrilling relationship that we’ve developed here.

Paddy: Thank you. Thank you. That was great and I really appreciate your time today. Tom. It was a great conversation I enjoyed it very much. And I look forward to staying in touch. Thank you again.

Tom: Thank you so much.

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

Thomas J. Grote leads the Banner|Aetna joint venture as Chief Executive Officer. He is responsible for building a sustainable model of healthcare enhanced by a distinctive member experience for joint venture members throughout Arizona. He is also responsible for enhancing product offerings while lowering costs, creating a clinically integrated network, and growing Banner|Aetna’s footprint throughout the state. Tom is accountable for the overall success of the health plan, and works to leverage the strengths of each partner to create an improved member experience within the Arizona healthcare delivery system. Prior to being named CEO of Banner|Aetna in 2017, Tom held various sales and profit & loss management roles throughout his 30-year career at Aetna. He was also a key contributor in the development of Aetna joint ventures in Northern Virginia and Northern California. Tom holds a Bachelor’s degree in finance from the University of Notre Dame and has obtained his Certified Employee Benefits Specialist designation.

About the host

Paddy is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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Our mission is to move consumers from an offline to an online relationship

Episode #20

Podcast with Aaron Martin, EVP and Chief Digital Officer, Providence St. Joseph Health

"Our mission is to move consumers from an offline to an online relationship"

paddy Hosted by Paddy Padmanabhan

In this episode, Aaron Martin discusses his role and responsibilities as the Chief Digital Officer of Providence St. Joseph Health, and covers a wide range of topics including patient engagement, the innovation model they follow, and the portfolio of digital health startups that he manages as the head of Providence Ventures.

For Providence St. Joseph Health, digital is all about moving consumers from an offline to an online relationship. The focus of digital health innovation is about prioritizing problems and identifying “needle-moving” solutions that can have a big impact. He believes that entities that deliver convenience, access, and personalization will win and keep patients in future.


He advises startups to have a “small story” which addresses the here and now of delivering returns to investors, as well as a “big story” which addresses the larger impact of the solution over time. More in the podcast.

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 talk about how they are driving change in their organizations.

Paddy: Hello everyone and welcome back to my podcast. This is Paddy and it is my great privilege and honor to have as my special guest today Aaron Martin, Executive Vice President and Chief Digital Officer of Providence Health. Aaron welcome to the show.

Aaron: Thank you so much Paddy. It’s great to be here.

Paddy: You’re welcome. So, let’s start with this. You have a fairly unique position within Providence Health and actually indeed within the healthcare sector. So maybe you want to tell us a little bit about the scope of your responsibilities as Chief Digital Officer and how that’s different from the current industry organization models.

Aaron: Sure. It’s fairly standard outside of healthcare. How I know that I’m a member of an organization that convenes 50 Chief Digital Officers from across different industries twice a year and it’s fairly standardized. And industries like retail banking, financial services, hospitality, places like that. Healthcare is of course a little bit behind. In my role again is pretty typical outside of health care but not too much inside of health care although that is changing. What rolls up to me is any consumer patient facing digital stack our digital interfaces reported to me. So that’s the digital part of what I do. We also have an incubator that creates new businesses and I’ll talk about that later in our discussion, as part of the digital part of what I do. So, I have responsibility over marketing. So that includes Brand, CRM, and the web sites or apps et cetera. And then the third part of what I do is I oversee Providence Ventures which has a $300 million venture fund basically that has 16 portfolio companies in it and is cooking on gas right now. So that’s kind of the scope of my responsibilities and I am happy to kind of talk more about that.

Paddy: Absolutely. And we will talk about all of those aspects. So, let’s start with digital and the definition of digital. In our work with all the health systems that I talk to the definition of digital varies from health system to health system. How do you define digital and how is digital let’s say different from traditional IT?

Aaron: Yeah well, I mean one way to think about is how we’re organized so. So again, my responsibility as anything is consumer facing digital tech stack, so you know again our web sites or apps anything the consumer sees, the patient sees. And then my counterpart B.J. Moore who comes from Microsoft. He’s the CIO, and he owns anything that’s caregiver facing so we call our employees caregivers anything that he owns basically our data lake and he also owns our enterprise systems relationships. So, you know Epic and Microsoft and those types of things. And so, if you think about it also kind of goes to what the mission of each part of those two different organizations are. Our mission is to move our relationships with consumers from an offline relationship to an online relationship. So, and that’s incredibly important to us in particular in health care because health care is a cross subsidized business on the provider side and so we make all of our money on the commercial side of the business. On a great day we kind of break even on Medicare and we lose money on Medicaid. And so, to sustain our mission into supporting the poor and vulnerable we have to do an exceptionally good job in digital engaging with the commercial population who is highly digitally engaged. And then also that part of our business is also at risk of being disrupted because if you look at all the disruptors in the marketplace whether it be startups, tech companies, or existing health care companies that are changing their models. They’re not going after the Medicaid population generally they’re going after the commercial population which is the high margin portion of our business and they’re going after it with better you know convenience and tools on BJ’s side of the net. He is really focusing on the caregiver productivity what is the experience like working for Providence St. Joseph. How do we leverage our data in new and interesting ways to improve the way that we deliver care? And then also our relationships with some of these big tech vendors in terms of how they’re going to support us.

Paddy: You know my firm did some research recently on the different organization models in the current state of digital transformation. More often than not the model we see is that the Chief Digital Officer role kind of folds into the CIO role. And it seems like at Providence Health these are two distinct roles and as you describe your role focuses more on the patient acquisition, patient engagement side of things. But the CIO is focused more on the enterprise side of things including caregiver enablement, caregiver productivity and so on. And of course, the innovation piece which in most organizations is actually a standalone unit as we see it through our research. It’s an interesting model and as you pointed out different other sectors of banking, retailing, and so on they have more of the kind of model that you just described.

Aaron: Yeah, I think it I think it has to do with the skill sets involved so. So, if you look at my background it’s e-commerce. So, working with Amazon for nine years you know how you engage with consumers online using digital tools. How do you enable transactions? How do you keep engagement etc? If you look outside of health care usually there is an individual who has that kind of background paired either with somebody who has a deep marketing background and brand background or vice versa. So, it’s either the Chief Marketing Officer has the Chief Digital Officer reporting to him or her or vice versa outside of health care. Inside of health care you’re right I think you see that much more you know the CDO and CIO kind of combined. But I think as health systems and insurers start to understand that these are very different problems to solve. You’ll start to see the Chief Digital Officer and Chief Marketing Officers you know those reporting relationships start to protocolize and get separated from the CIO which is a very different set of skills around you know how do you deliver a technology at massive scale. You know serving your employees, how do you deal with massive amounts of enterprise data and then how do you manage very complex relationships with technology partners, vendor partners who are helping with those two other issues. So that’s kind of how it nets out outside of health care we’ll see what healthcare does with it.

Paddy: Right. So actually, that’s a good segway to what I was going to ask you about next. You mentioned you came from outside the industry. What do you see as an outsider looking in as the biggest opportunities and the biggest barriers to technology-led innovation and maybe you can talk a little bit about your innovation model as well?

Aaron: Yeah I mean I think there’s many opportunities and the problem is been prioritization and so one of the first problems that we’ve fixed within our organization and fixed is a stretch. I mean I think we’re on a journey around this is how do you prioritize the problems into what we call needle movers and how we’ve done that is I work with our head of our digital strategy Sara Vaezy who leads a team that, think of it as an internal consulting team, what they do is they work with our clinical and operations leaders from across our hundred sixteen thousand person organization to identify and then scope, and size, and prioritize these needle movers. And so, we do that in a big way every three years and so we’re going through a refresh of that now and then we do it incrementally every single year obviously. And to give you an idea we’ve identified literally a hundred problems that hit our radar from these discussions and we’re boiling it down to kind of the top thirty-five and we’re actually putting a value against them. So, you know if we solve this problem what is it worth to us. That could be in terms of economic value, it could be in terms of clinical value, in terms of mission. But you know we’re putting some sort of value metric on it. And then what we do is we start to engage the organization around how are we gonna solve that problem. Does it have a digital, if not solution a digital, approach to it that might be helpful and then we go through our innovation models kind of starting from there and I’m happy to kind of walk you through that if that would be helpful.

Paddy: Oh, absolutely I think for the benefit of our listeners we would definitely love to hear about your innovation model. You used an interesting term needle mover. Maybe you can talk about a couple of the big needle moving problems that you try to address and maybe talk to us in terms of how you apply your innovation model to those topics.

Aaron: So, a good example of one that we’re furthest along with is we call it convenience access and personalization. So, the problem we’re trying to solve is healthcare is generally none of those things so it’s not being yet there’s low levels of access and it’s definitely not personalized. And so, what we’re trying to do is change those to you know from kind of bugs until to features. This the kind of way that we kind of went through that and the economic value around that is again you know especially in the commercial market the thesis is that the entity that gets there first and kind of delivering that on those three areas will win and engage not only win the most new customers especially in the commercial market that will win the most new patients and turn and keep them because of this engagement model. And so, what we did again to kind of we took the 100 problems or so narrowed them down you know _____ [unclear] and personalization was a big part of the problem. We then further broke that down and obviously went through a sizing and prioritization of what is this worth to us. And then we went through a very kind of deliberate set of steps. And so, step one is we call it the tech cascade and it involves kind of three steps. The first one is do we already own a solution to that problem. So, if Epic or Microsoft or one of our enterprise solutions that BJ oversees our CIO can solve the problem great let’s use that. Because we’re already paying for the technology why you know go and get something different just for the sake of difference. And so that’s step one. If not, then we go to step two. And then that’s where Providence Venture Fund comes from and what they do is they go out and they scan the market for what we call best of breed solutions and so they’ll go out and look for just incredible companies that just really solve that problem. So the example I always like to use because we’re investors and I’m on their board is coming called Kyruus what they do is they have really solve the problem of physician search match and book where they’ve created a platform that maintains and integrates at source of truth down to the credentialing levels and the source systems all the way up to call centers and on the web site. So that you have an accurate provider directory and you can book with those providers online and to really solve that problem. That’s an example of a company that we went out there and found and we actually worked with them for 18 months before and then we decide to invest after that right. So again, so going back to the tech cascade do you have it already, can you find it. So, in the case of finding it we found Kyruus for the physician’s search, match, and book part of the convenience personalization and access problem. And then what we did is as we know if we don’t have, can’t find it, then we will actually build it. And so, what’s unique about our health system as I mentioned is, we’ve got about 85 software engineers and product folks from places like Amazon and Microsoft based here in Seattle. I’m sitting on the same floor as my team here in Seattle. And what they do is they create new companies where we find white space or existing solutions, we believe aren’t going to solve the problem. And so, they basically go through that very deliberate process. There where they’ll first setup and create the technology determine if it works or not. And then the second thing we’ll do is once we run it for a while and determined it works, we can scale it then we’ll actually sell that technology to another health system. And then once we saw that ____ [unclear] another health system we will recruit a management team. Even though Providence Ventures will lead deals outside of companies that we incubate, we typically try to avoid leading deals with companies that we do incubate. So, what happens is you know these incubated companies are going through a series of very you know arm’s length in a validation. The first one is does it work. The second is you know is it valuable enough for not only us to use it but for another health system actually write a check for it. This is a huge validation step. Third validation step is it valuable enough as a business so that a very experienced senior management team will come in and run it as a business. We’ll be excited about running it as a business. And then if it’s kind of beyond that if it’s those two hurdles are cleared will an uninterested or a third-party venture firm come in and actually revalidate as a potential business and tell us what the equity of this company is worth. So that again got an unbiased third-party kind of weighing in on it. And so, the example I know you spoke to the CEO of Xealth, Mike McSherry built a technology, hired them as a senior management team. UPMC was the second customer and then DFJ came in and financed it. So that’s the kind of model we’ve got there. So just to kind of summarize like if we had it great, we’ll start stop there and we’ll let Epic solve the problem or Microsoft or whoever. If not, then we’ll get Province Ventures go out and look for a solution. If they can’t find a best of breed solution then as a last resort, we’ll build it, but we’ll build it with the idea that we’re going to spin it out. And the reason is because we’re not Microsoft, or not Amazon, we’re not Google. We don’t have unlimited development resources and we can’t prosecute a roadmap indefinitely. And so, what we have to do is leverage the venture community and other customers of this technology to extend that roadmap and get more people working on it. So, as a data point when Mike and team first start off with Xealth, I think that four or five people working on the team now they’ve got over 40.

Paddy: Right. You know Xealth is a fascinating story. And Mike was on my podcast episodes ago and one of the things he said which stuck with me was that. For digital health solutions to be successful he said they have to be “doctor prescribed”. What he was trying to say is that unless you have the clinician on board, you’re going to struggle to gain an option. So, can you talk a little bit about your own views on what drives digital health adoption and what kind of structural issues do you see impacting the success of companies like Kyruus and Xealth.

Aaron: So yeah, I think Kyruus and Xealth are really good examples of two different ways that digital adoption occurs. I totally agree with Mike around his comment and that’s the reason why we built and partnered with Mike and team to build what Xealth is. We were looking as a health system the adoption of some of the technologies we’re putting out there by patients. And it was reasonable but still kind of a bit low. And then we looked at we have our own health plan and was far far worse. And so, with health plans you know if you look at how they kind of work with their members, the members aren’t really that well engaged. You know they kind of not see them if they’re healthy you know a few times a year. You know the thing I always tell people is when I was at Amazon, I probably visited our benefits web site once in nine years right. So, I could even for sure unless I pulled my card out tell you who I was covered by and it’s because you know out of sight out of mind. And so, the struggle that health plans have is getting engagement with their members so that you know their members they can improve their members health and then same thing happens with health systems who are also trying to improve the health of their patients. And so the problem what Xealth serves for is you know and Mike and I and the rest of the team were kind of thinking through the problem you know it sounds obvious when you say it out loud but you know it took us a while to get there which is if you abstract everything you know what is the most effective way that technology is adopted in health care and it’s by the physician’s pen. So if you know if you think of biopharmaceutical is nothing more than just technology to help people or medical devices that’s all prescribed and then we thought about it well you know then the problem seems to be that channels is very narrow and very specific to biopharmaceuticals, is why can’t it be expanded to digital therapeutics, apps, content, left right, social determinants and in and anything that can be prescribed through your URL. So that was a huge breakthrough and it’s the reason why we’re so excited about Xealth and the reason why they’re getting so much traction with health systems and then now have a lot of. I was just on a call this morning with a very very large payer who is very familiar with Xealth and they recognized immediately the challenge that they’ve got and how Xealth can be helpful. Right. So, it’s you know its kind of SureScripts for everything else right. Then on the flip side you know Kyruus this is a different situation in that. You know patients are coming to us today trying to book appointments what Kyruus this does not really increase the volume of that adoption. I mean it happens today and you know we have you know millions of patients a year come in to see us. You know it’s really increasing the effectiveness of matching them with the right provider. Right. And so that’s what they’re doing is increasing the efficiency of that because what happens in that space is they drive up what you know Amazon would call it conversion rate which is you know how many people hit the website and actually find what they’re looking for and by. While in our case its patients searching for a physician. And how likely is it for them to get matched with the cardiologists that they want to see. So that’s what Kyruus does. There’re slightly different use cases. In one case Xealth is actually creating a new channel that didn’t exist before and Kyruus is improving on one of the oldest channels there are in terms of getting help and assistance.

Paddy: Right fascinating story is you know I just wanted to make one quick comment. Sometime back one of my guests on this podcast was the Chief Analytics Officer of Premera and Premera of course is the big health plan in your part of the country. They kind of referred to the same issues in terms of the demographic makeup of the Pacific Northwest. You know young invincible they don’t feel the need to go to a doctor. How do you engage with folks who don’t feel the need to engage because they are healthy and active and so on? So, it’s very interesting. You know I heard the flip side of the coin from your comments as well which is very interesting and I imagine that depending on the demographics of the region in which the solutions are being rolled out you would have a different adoption rates. Just because of all the differences in the demographics. Is that a fair statement?

Aaron: Yeah, I think it is. I think you know that said I think the problem is pretty pervasive and then you’re also going to see this happen and Medicare advantage in that as well. So, you know don’t forget the biggest part of the Medicare population is now growing at a ten thousand per person rate. People kind of crossing 65 right now per day. All those folks are highly digitally engaged right like those folks you know my dad’s seventy five and he’s on his phone more than I am and I think what’s different is the popularity of Medicare advantage has really driven the ability for these plans to again provide other helpful services to that population. And the problem is they’re not aware of it and they are not going to go to their plan to go find out they’re going to go visit their physician to go find out what they need to go to use.

Paddy: Right. OK so one of the things that I do on my podcast is something called a lightning round with my guests. In the lightning I ask you for your top of mind thoughts on a handful of emerging technologies. After all we’re talking about technology led digital health innovations. So just a few here. So, the first one on my list is artificial intelligence and machine learning.

Aaron: Yeah, I think the two areas my team is very focused on are actually three is basically digital bots on the front end to help with navigation, disease prediction, and to a lesser extent kind of helping the patient be treated more efficiently. So, we’re definitely looking at that space and we’ve experimented with our own bot we call it Grace and it’s a bot that helps with navigation on our website. My thinking about that is you’re going to see that technology become pervasive and it’s also going to be contextually aware over time which will be awesome. And it will have the same it’ll have a personalized personality for you over time. And so you know our hope is Grace is present when we first kind of make contact with you when you’re trying to figure out where to go within our health system all the way through treatment, through kind of follow up, and that kind of thing and you get to work with Grace and it is helpful to kind of help navigate through all day. As we simplify the health system that will navigate you through that complexity all along the way. An extension of those types of technologies, technologies that are already in the home, so we were one of the first health care organizations to work with Amazon on their HIPAA enabled Alexa. And that was super fun and the reason why we were able to do it so fast is because of all the infrastructure and technology we put in place prior that made it easier to develop for that technology and so you can see a lot more of those types of things happen. And then the third area that we’re doing a lot of investigation around is in clinic AI in which you know the physician is able to you know passively talk without having to invoke a bot and then that bot basically effectively acts as a virtual scribe or a digital scribe and takes that note. Eventually it will take the order and then the physician kind of goes through it and checks that everything’s appropriate and push on so that they’re having to deal with the EMR ______ [unclear].

Paddy: It’s a fascinating news because I actually wrote about chatbots in healthcare in one of my recent blogs and I actually called out Grace as a great example. I am happy to share that with you. So, you know symptom triage is one of the most basic things where anyone has an urgent care need. What’s the first thing they do they go on Dr. Google right. Google is not exactly the recommended standard of care but like it or not that’s what people do. And so yes, it’s a great opportunity for health systems and clinicians to really make these tools available to people at the time of need. And at least you know even if you can’t go too deep into the triage especially with a complex case and so on. But at least for the vast majority of routine care need you can at least guide your patients or your consumer. So, I thought this a fascinating use and the possibilities for machine learning to really make the engine smarter and smarter over time. It opens up endless possibilities and of course let’s not forget that there is an acute crisis in terms of shortage of skilled clinical staff. The chatbots solves for that problem as well.

Aaron: You know on that last piece I’ll just kind of amplify what you just said. I was on a panel and the audience was full of physicians and so I think one of the questions that I was asked was you know do you think that AI would be involved in not only triage and disease prediction but also in diagnosis and treatments. While other fellow panelists were being a little bit more deferential than I was and they were kind of saying well not sure if that’s going to go all the way and whatever and my response was God I hope so. And people were kind of shocked to that statement. I said look if you just do the math on the number of patients that are going to need care and number of physicians, nurses, MAs etc. that we’ll be able to provide care. It doesn’t pencil out so you’re going to have to figure out a way of you know kind of with these kind of low risk, low acuity, urgent care types of scenarios where a bot can do those types of very basic things. If we don’t figure that out, we’ve got a huge supply demand mismatch and they’ll be rationing of healthcare which I’m super not in favor of.

Paddy: Right. You know we’ve covered two of the items on my list of the lightning round. I have one more which is also related to this topic that I wanted to get your thoughts on – voice recognition.

Aaron: Yeah, I think that’s kind of related to kind of in our world it’s going to be related to digital scribing. So, in our world that is going to be a big part of it as well as you know kind of the bots at home. So again, you know we’re kind of as in the Amazon. Amazon would say we’re kind of at day one and all this technology is super early. So like right now we’ve trained Alexa in a HIPAA compliant way to find the nearest retail healthcare location to the individual and book an appointment right like the super basic. But you kind of see where that could go in the future and you can also see how the Alexa team has done some pretty amazing things with other partners around delivering content in specific ways and et cetera, et cetera. So, I think what you want to have is more access, that’s more convenient, and then it’s pervasive and engaging. You know I think the biggest part of the problem with healthcare right now at least from taking it from a tech angle is you know people especially the poor and vulnerable and the Medicaid population these kinds of vulnerable populations have limited access. It’s super inconvenient and one of things I always talk about in a big part of my passion is I always talk about how inconvenience hurts the vulnerable populations way more than it does middle and upper income. And the reason is you just kind of sit down and think about it. If you’re a working mother with one possibly even two jobs and one of your kids get sick, it’s a huge economic problem for you because you’re taking off. Best case scenario half a day’s work you have to travel to and fro a clinic which is probably not conveniently located, get seen by the physician and so on. So, you’re out whatever your co-pay is you’re out. The time you know that it took, and you know in terms of wages you could’ve earned it’s massively bad. So, it’s not surprising that people pick the most rational choice which is to go and go to the ED after hours. Which is the most expensive care venue. And so, you know a good example of what we’re doing around low acuity is trying to make it so convenient that you know why I would ever go to the ED for something minor right. Even if I have that situation right.

Paddy: Yeah. You know you alluded to this earlier access and convenience these are possibly among the top two challenges for health systems today. You look at it both from the clinician standpoint as well as from the healthcare consumer standpoint. These emerging technologies can only alleviate the situation and improve the situation. But I hope that man and machine together can actually address this massive problem that we have when it comes to access. So let’s switch topics we’re coming up to the end here. But I do want to touch on a couple of things. You mentioned big tech in healthcare, and I know that Providence Health just announced a big contract with Microsoft around digital transformation. All the big names like Apple, Google, Microsoft, Amazon they all have big ambitions for healthcare, but they all have slightly different approaches to the market. Of course, none of them is building the last mile solution. The innovative solutions that your portfolio companies are investing and building like Xealth and Kyruus. And we need dozens of dozens of those. That’s a whole separate issue in terms of mortality rates or whatever and we’ll talk about that separately. But what is your general sense of how big tech is coming along in healthcare and where do you see them in the sort of a steady state scenario of digital transformation in healthcare.

Aaron: Yeah, I mean if you not talking about any of them in particular but just kind of lumping them all together. You know what I’ll say is you know the fundamental they will all to a greater or lesser extent dabble in care provision would be my guess. Just basically for the purposes I think of learning healthcare and not necessarily being in the business of healthcare delivery. And the reason is this I just always I jokingly tell people I don’t know how that meeting with Jeff Bezos would go where you’re like OK I got this great idea. Why don’t we go into a kind of a 1 percent NOI business that has all these kind of legal and regulatory issues, huge amount of risk, it is hard to scale. You know I just can’t imagine what that conversation would be, or you know Tim Cook or whoever. I think rather they’re going to continue to do the things they already do which is at a high level bring more information to the party, make it more scalable to deliver care and then also shift demand around and get paid for it. Which is basically what all of them kind of do right and help consumers make better choices. And that’s the reason why a consumer would want to pay them to do that right effectively. So, I think you know if you look at all their different business models that’s what they do. And I think they will be partners. Every single one of them in various different ways with health systems and less competitors over time on a steady state basis. So, I had an interesting conversation with the leader of one of those organizations and they laid out a really great vision of how they would go after say chronic disease management or something like that. And I said that’s great. It sounds like though what we’ve got to be ready as an industry is, we need to be transaction ready and this person was like what do you mean by that and I said well. We have to collectively as a health system build infrastructure by which we can send receive and book any resource that we have. And then also be able to provide information around. The quality and the pricing of that transaction. And this person said yeah, you’re exactly right. And so, I can’t imagine them. And so I think one of the discussions we’ve been having as it is as an organization with other health systems is let’s get that part ready because even if you know that future is not true where Google with its very high browser market share and it’s you know it’s very high share of the search business or Amazon of its very high search sheriff ecommerce, or Apple of phones, or Microsoft enterprise software. Even if none of that comes _____ [unclear] which I can’t imagine it wouldn’t but let’s say it doesn’t. At least you’ve got a better experience for your consumer right. But then what will happen is there will be these different new models that they’ll need to collaborate with existing health systems in various different ways. And they will you know one of the important variables that they will pick is who’s ready. And the reason why I know that is you know back when I was at Amazon and we were my team was responsible for getting selection onto the Kindle in North America. You know a big variable was which publisher had their books ready to be put on Kindle. So, we’ve been really kind of because we’re not competitive with most of our counterparts across the health system. You know in other regions just give you a statistic. We’ve met with you know now over 100 health systems in the past 24 months have come to Seattle on that with us. And it’s an interesting discussion about how to get ready as an industry. For these changes that are coming. It boils down to at least on the front end side of things you’ve got to get really good at I mean one of the key things that are emerging at least for me have been you know you have to do an exceptional job at your core business which is you know delivering high quality care at a reasonable cost i.e. value. You have to learn to manage risk like population health/ insurance risk. That’s the second thing you have to do. The third thing you have to do is you have to have an awesome brand. And then the fourth thing you have to do is you have to be digitally ready to partner because there’s gonna be a whole bunch of different partnership opportunities. And what I don’t want to have happen is have four or five six seven different platforms that we have to integrate to. I would much prefer health systems to create a set of standards by which these different partners in the future can kind of integrate. So that the complexity on our side doesn’t grow.

Paddy: Right. In many ways it seems to me Aaron that this is we are right now at a stage where the battle is for the attention of the consumer in a primary care setting. Where does the consumer go first when there is ______[unclear]. And so, I feel like there’s a lot of activity around trying to gain control over that primary care experience. So, it’s not just the big tech firms and you look at all the non-traditional players CVS, Walgreens. They are also getting into this space. You know Walmart potentially.

Aaron: So yeah, I am more concerned about CVS/Aetna than I am about an Amazon. And the reason is because they’re actually in the business of providing care. Amazon is not. And so, it would be much more plausible for them to do a great job of competing with us on the full spectrum to your point.

Paddy: Right. Well the flip side to the big tech question is obviously digital health startups and that’s the world you live in at least the part of your daily life going up and working with them. So, you know 10 billion in VC money every year give or take literally hundreds of digital health startups. Many of the you know don’t make it. So, what’s your state of the union comment on the whole digital health startup environment?

Aaron: I think it’s very healthy assuming you know I mean I’ll give you kind of like the things I tell health tech CEOs based on my experience so far in health tech which is you know if you kind of follow these rules and this mainly has to do with the health techs solutions that are selling on the provider side. That’s the context for these comments. Well first thing I say is you’ve got to have a what I call a small story and a big story. So, this small story is how are you going to deliver value in the next 6-18 months to whoever you’re selling to. If you don’t have that nailed down to where there’s actually like a financial payback then matter. I mean you’re not going to get anywhere at scale. That’s one comment. The second comment is then the big story is got to be like all right this is much more for the VCs and you know the Chief Digital Officers of where this is going. If you saw that first problem that small story whereas the big story you know convinced me that this doesn’t just become an interesting kind of point solution that becomes a bigger solution over time that you’ve earned the right to kind of you know build based on your success with the small story. So that’s the first thing you know I would say to exact. And then the second thing is making sure the problem you’re working on is like on the top 10 or 15 agenda of a health system. That’s what we call a needle mover. The problem you can run into in healthcare is it’s the land of opportunity. And you know there is a ton of smaller problems that you know your solution will have an NPV positive effect on, but it won’t get traction within the health system or insurer or whoever because it’s not top of mind at the CEO level. Right. And so, it’s got to be one of these needle movers in my opinion because otherwise you know it’s just not going to get the attention. You know the third area is don’t overbuild your company a lot of these technologies come from outside of health care where they’re super freaked out about. You know because they’ve been trained in this you know outside of healthcare like wow this is a perishable opportunity if we don’t get our share super quick. You know it’s gonna go away et cetera et cetera. And then I see a lot of overbuilding companies from a product standpoint as well as a sales force standpoint. Most health systems will not be able to consume the amount of future development that you’re able to deliver with the product team. And then on the flip side you know the sales cycles are very very long. So, they’re 12 to 18 months. And so, if you don’t need a 50-person sales force to cover the top two hundred sales health systems. You need probably four or five right to do it effectively because there’s not that much activity between calls.

Paddy: Yeah, you know this is fascinating because what you talked back a little bit. You don’t want many of these digital start startups started as B2C business. They wanted bypass the clinician patient relationship. They figured out that’s not going to work. So, they’ve now pivoted to B2B but B2B moves more slowly and helped it is not a winner take all market, this is what John Sculley the former CEO of Apple said, he was on my podcast recently. This is not the winner-take-all-the-market and most startups think they’re the next Uber or Facebook or whoever they’re used to they are wined of this whole thinking process of hey it’s a winner take all market if you’re not the winner you’re not going to take any part of the market.

Aaron: And I think it is a winner-take-all. So, we have one portfolio coming up we’ll tell you who has one and they’ve said they’re taking all but it’s not because it’s a winner-take-all-market it’s because their competitors just couldn’t survive that chasm. And so, these guys were very very _____[unclear] in terms of you know not overbuilding focusing on you know kind of the areas that we were. We’ve been talking about and just you know just being around when the segment of the software that they’re working on gets defined and you know people say oh this is a thing now I need to buy it. They ended up being a winner take all just because they were around, but you had these other CEOs kind of you know headed down this path of like all right. We are probably be two three major competitors in this market. It’s a big market so.

Paddy: Right. Well Aaron we’ve pretty much come up to the end of our time here. And this has been a truly fascinating conversation and thank you so much for sharing your thoughts, sharing so much information about the work that you’re doing. It seems like really exciting stuff. I wish you and everyone in your team all the very best and I look forward to staying in touch.

Aaron: Thank you so much for the opportunity I really appreciate it.

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

Aaron is Executive Vice President, Chief Digital Officer, Providence St. Joseph Health (PSJH), and Managing General Partner, Providence Ventures (PV). Providence St. Joseph Health is a not-for-profit health system that combines Providence Health & Services and St. Joseph Health. Both organizations have served the Western U.S. for more than a century and together comprise 106,000 caregivers who serve in 50 hospitals, 829 clinics and hundreds of programs and services. Aaron is responsible for digital and marketing for PSJH. His team is also responsible for driving innovative new programs across PSJH that improve convenience, lower cost and improve quality. Aaron is also responsible for Providence Venture’s $150M fund which invests in early to mid-stage health care technology companies. Aaron serves as on the boards of PV portfolio companies AVIA, Kyruus, Wildflower Health and Xealth. Aaron is a current board member of Presbyterian Healthcare Services, an integrated not-for-profit health system based in Albuquerque, NM.

Prior to PHS, Aaron worked for Amazon, McKinsey & Company, and was a founder of two early-stage technology companies funded by New Enterprise Associates and Mayfield. While at Amazon, Aaron was general manager of Amazon’s self-publishing and print on demand business. Aaron went on to lead the Kindle North American Trade publisher business helping major publishing partners like Random House, Simon & Schuster and Harper Collins transition their businesses to ebooks on Kindle.

About the host

Paddy is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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Digital innovation is an applied science

Episode #19

Podcast with Manu Tandon, Chief Information Officer, Beth Israel Deaconess Medical Center

"Digital innovation is an applied science"

paddy Hosted by Paddy Padmanabhan

In this episode, Manu Tandon discusses how Beth Israel Deaconess Medical Center, a Harvard Medical School-affiliated academic medical center, is working towards their mission to bring in innovations that are happening outside of healthcare.

Digital innovation is an applied science; it is about finding new ways to solve existing problems through emerging or sometimes through traditional technologies as well. At Beth Israel Deaconess Medical Center (BIDMC), a core part of the overall technology stack is their homegrown EHR system. BIDMC is the only health system in the country to run their own EHR system. In this podcast, Manu Tandon discusses the many benefits and challenges that arise from having a homegrown EHR system.

BIDMC is in the process of migrating their existing services substantially to the AWS cloud platform; this has opened the gateway to new and innovative technology solutions for BIDMC’s digital transformation journey. Tandon advises digital health startups to focus on workflow integration and points out that creating new, technically smart solutions is not the only way to achieve success with digital health solutions; people and process matter as much as technology in the journey of digital innovation.

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. Talk about how they are driving change in their organizations.

Paddy: Hello again everyone. Welcome back to my podcast. This is Paddy and it is my great privilege and honor to have as my special guest today Manu Tandon, CIO of the Beth Israel Deaconess Medical Center which is an affiliate of the Harvard Medical School. Manu welcome to the show.

Manu: Thanks Paddy. Thanks for having me. It’s an honor to be here.

Paddy: Thank you so much. So just to set the record straight and for our listeners to really understand the structure. So, Beth Israel had a recent restructuring right back in March I believe you want to just quickly walk us through what the current structure of the Beth Israel health system is.

Manu: Sure the BIDMC which is Beth Israel Deaconess Medical Center as you mentioned is academic medical centers, Boston- based, it’s a non-for-profit, is affiliated with the Harvard Medical School, located in downtown Boston as a tertiary quadrant care hospital with about 670 beds. On a research side receives about 170 million in research funding. And like you mentioned back in March we just became part of a bigger system the name of the new system is Beth Israel Lahey health (BILH). BILH is bringing together about 13 hospitals, few AMCs, committee hospitals and is super excited about this new development and I will say that we are in a early form of our merger. And so, there is a lot to figure out but a lot of exciting thoughts and exciting stuff that’s happening around it right.

Paddy: Right. And I know that BIDMC also launched a Center for Health IT Exploration and John Halamka was on my podcast last week and I guess that’s also part of the overall health system. Is that right?

Manu: That’s right. John and I work fairly-closely. John’s looking at the BILH level innovation market space. He does a lot of work internationally and nationally. We at BIDMC has something called a Center for IT Exploration which is like you said a little bit more focused on the academic medical center, more tied with the annual operating goals of the hospital and you know our mission here at the CITEx, which is the short for Center for IT Exploration, is to look at innovations that are happening outside of healthcare and trying to bring them into healthcare but under the context of our operating plans. If our operating plan says hey our number one problem is to maximize our existing capacity, then we are looking always looking for solutions that can help us with doing that. I hope to talk to you about a few of those as we go along today.

Paddy: Excellent. So we met Manu when I attended the Executive Education program at the Harvard Med School where you gave a fascinating presentation on your IT environment and the thing that struck me the most was that you are the only major health system in the country to run your own electronic health records system. So, you tell us a little bit about how that came about for the benefit of my listeners and why the Beth Israel Deaconess Center choosen not to implement one of the major industries EHR platforms to date.

Manu: Yeah. So, I think I’ve been here only for four and five years. Our EHR obviously predates me, several very highly talented folks have touched it as it has gone along. Back in 1970 it started with an NIH grant to two doctors Warren Slack and Howard Ablation. They were trying to build a system which was patient centered and I guess they were more patient centric at the time before such a term even existed. And so, what they did was they had this notion of usability and workflow to be central to the development of such a system. They started out with building actually a master patient index with about five hundred thousand patients which is what we had at the time and then sort of one thing kept leading to another and over time they added you know clinical ancillary systems like labs and radiology, and the diagnostic, administrative systems like registration, admitting, outpatient appointment, charge capture systems, clinical documentation. So, this has now grown into what we call OMR. And then includes basically the entire gamut of EHR functionality in 2004. We launched web OMR, which was basically a web-based version of OMR. So that’s kind of where we are right now in terms of your question of why we still use it. It works within the four boundaries of the hospital fairly-well; it compares quite favorably and provider satisfaction surveys. We occasionally compare its functionality to the leading EHR vendors, and it seems to fairly okay on that account as well. As I mentioned is browser based so that has some advantages to it. It’s accessible from any browser running on any device anywhere. I will also add that having your own EHR allows us to control the workflows and as I’m sure you know one of the biggest adoption barriers to innovations and third-party innovation especially is workflow integration. So, we seem to not have that issue. I think this combination that we have has resonated with several innovators like Amazon, Google, and MIT with whom we have quite fruitful partnerships. I will say it does come with challenges. Interoperability is I will say as a national level it remains a challenge and you know keeping up with interoperability is a challenge, I think. You know occasionally we have to go through certifications that draw resources to it regulatory requirements state or federal. And I think now that we are part of a big system as I mentioned the top of the call on your prompt. You know I think we are taking a look at safe handoffs of patients within the system and where do we go with our EMR. But I would say we’re all where we are right now. You know the EMR works quite well like I said within the four walls of the hospital it provides a good core platform if you may for workflow integration, for innovative solutions which we see as a differentiator. And then obviously it helps that it is very friendly to the bottom line as it comes at a very tiny fraction of what it would cost otherwise. And we have been blessed to have great staff highly skilled, dedicated. Even after so many years, Paddy, of its existence we are still rolling out more than a dozen enhancements every month to it. So, it’s a very robust environment.

Paddy: That’s a fascinating story actually. So, can you talk a little bit about the overall technology stack and the ideas we see that you manage and a little bit about the high-tech governance model.

Manu: Sure. So, the tech stack, we spent some time talking about it. The core of our tech stack is our homegrown EHR system. But then we have all the typical applications you would imagine you know PeopleSoft; we use PeopleSoft software for HR finance, supply chain, several websites, revenue cycle system. We are in the middle of a multi-year project to migrate to the Amazon Web Services public cloud. So, at this point we are about 50 percent migrated. Over the course of the next year and a half we expect to complete that project. I will also say that besides having a core EHR we have been, as we have been thinking about our digital strategy. We have been thinking about expanding, if you may, our core EHR platform by adding three additional platforms that work fairly closely with our core EHR platforms. I would say those are our mobile platform where we are able to add mobile apps that work well with our EHR. We have added a location services beacon/ IoT platform and we have added natural language processing NLP platform and all these additional new platforms that I mentioned are all hosted on AWS. So, we have sort of a hybrid data center model going on. I will say that culturally we are kind of like a product shop within a hospital, if you may, because we have a full stack of as you can imagine we have developers, architects, designers, analysts, testers. So, we are more like a software shop that way more traditional software shop within the hospital. That’s what our tech stack looks like. In terms of your second question on governance which by the way I want to say that’s a really key question and sometimes often overlooked. So, I congratulate you for asking about it. It’s probably a session that I can talk forever on, but I will just summarize by saying that we take governance very seriously. We have four components to it. We have a steering committee with about 24 members that owns the strategic plan. The second component of our governance is a fairly straightforward way for anyone to make any IP requests. In fact, since we have put that new process, we have seen about a 300 percent uptick in the number of distinct users that make the request. The third part of our governance process is a robust upfront triaging system which is really where we put our smartest people, I call that part of the secret sauce of governance. In the final leg of our governance is a transparent system for reporting progress to stakeholders. I think the reason is critical because the governance process allows us to what I will say establish trust, transparency, and accountability and I think those three are prerequisites before one can launch innovation and digital solutions.

Paddy: Right. So, you mentioned digital strategy in my podcast. We talk a lot about digital strategy and digital transformation. Our research and everything that we see in the market and all the CIOs and everyone else that I talk to suggests to us that healthcare is still in early stages of a digital transformation. The definition of digital varies from health system to health system. So, can you talk to us a little bit about how you’re approaching digital and what are some of your key priorities. You talked about a couple of those earlier but how do you treat digital differently.

Manu: When I think about this, I can go back to like what is digital innovation. Is it the development of new capabilities or is it really something else? And I guess you know different folks have different opinions about it but where I personally land on this, I think that pure new capabilities I think emerge from real science or pure science. And I think you know I call them innovations and discoveries. To me digital innovation is an applied science. It’s about making connections. It’s about finding new ways to perform existing functions. It’s about seeing a business problem from a 360-degree view. Understanding the people process and technology components that are playing into it and then really creating a solution that leverages either new or in fact just sometimes traditional technologies in a new connected way which to me is the innovation part of it. In terms of how we handle it internally we don’t necessarily differentiate between the innovation stream and the more, let’s just say, conventional stream. We have one common process for our users to engage IT regardless of whether they are looking for a traditional or a digital platform. Like I mentioned earlier we are a common triaging process that really acts like a matchmaker if you may between business problems and the right technology platform whether that’s a new innovative technology or existing technology. And I would say that organic growth of innovation within our otherwise product-oriented development shop has served us fairly well and that’s how we see ourselves continuing down this journey.

Paddy: So, the way you’re defining digital innovation as you take emerging or existing technologies or traditional IT, you find new ways to do things that are better faster, cheaper, better experience. Is that a reasonable summary?

Manu: That’s a perfect summary.

Paddy: Very good. Now are you also the Chief Digital Officer by definition? Is there is a formally named title or is the CIO also the Chief Digital Officer at BIDCM?

Manu: We have one unified team I would say. So, the quick answer is no we don’t have a Chief Digital Officer. We have what I would say one unified team all under the CIO. So, when I say unified team, I am including our core operations, we run a 24/7 hospital after all, as all likely needed to support that. It also includes our entire EHR product stack that we talked about a little back. And then it also includes our Center for IT Exploration that we refer to the top of the call which is really our innovation arm. It’s all under one team, one triaging system, one way to engage, one budget if you may. And a lot of the staff that works into these three streams intermingle and sometimes move on from one role to another quite a bit. I would say Paddy, that’s a conscious choice we made it to do it this way. Sometimes doing it this way may seem like it can slow things down. I know a lot of organizations have taken a different sort of part to this where they have created the center of innovation sort of outside of operations. We chose to not do that. We chose to keep it in operations because I believe in the long run that’s more scalable and plus the solutions that come out of the innovation side. If you may get absorbed better in the operational side and are sustained longer and in a more informed way by our staff when you do it in a combined unified way like I defined.

Paddy: Right and I think you are a little bit unique in that regard because as you pointed out what I see in the broader world of health systems is that the innovation group tends to be a standalone unit at least among the larger health systems. The digital and the IT function are kind of rolled into the same role. Is that also your observation? Do you kind of agree with that statement?

Manu: Yeah that’s exactly right. So, we thought hard about that and made the choice that we made for the reasons that I explained.

Paddy: Right. Now let’s talk about digital strategy itself within your health system. What we are seeing in other health systems is that there’s multiple models for driving digital strategy. At one end we have a model where they say our EHR system is our digital strategy. So, you know fill in the blank with whatever EHR vendor name you want to put in it. That’s their digital strategy. At the other extreme we have enterprises that are taking a step back and looking at an enterprise level digital roadmap and prioritizing all the initiatives and aligning them with enterprise level strategy and goals. What we see mostly though is that digital is being driven as a portfolio of individual projects each of which is evaluated on its own merit and its own unique business case. Do you agree that is the predominant model today? Where do you see yourself in that continuum as far as an overarching enterprise level digital strategy is concerned?

Manu: Yeah, I mean I would talk to this question just based on my own experience. Like I mentioned, our story starts with having our own EHR which as we talked previously. We have paid a lot of attention on governance, a common governance process and on a conscious effort to build more platforms that support that core EHR and I feel that with those three things in place a core EHR, a strong governance process, and an expansion of platforms. I think beyond that to me the journey needs to be driven by the priorities of the hospital and so in our example our President Peter Healy and his senior management team which I am a part of. You know we every year sit down and set up our operating plan and whatever comes out of that is essentially our charter for our digital strategy that we build off. And maybe I can best explain this with a few examples. For example, one of our operating goals was to maximize our existing capacity. And one of the things we found out was the discharge process could be expedited for example if we were able to notify physicians of the availability of a result that perhaps is the last thing waiting between a patient getting discharged. So, you know we could use our some of our mobile platform in that particular example to build a mobile app that notifies the clinician smartphones or even their watch that results back and with one click. Given that it’s a browser-based system takes them into the EHR where they can put in the discharge note order and then the patient can be discharged. Why is that important because that maximizes capacity, it doesn’t make someone stay here any longer than they need to. Another example is you know in hospitals like ours the operating rooms are the biggest focus of both resources and opportunity. And I don’t know if you know how operating rooms or blocks are utilized but it basically boils down to every surgeon having sort of a slice of time if you may where they can book their patients into. Now, if a surgeon is not going to be there say two months from now or let’s say two weeks from now because they’re going to go on vacation or something and they say release their block. How do you make sure that release block gets rebooked? And there’s a rare use case where we thought that a simple mobile app that could notify unexpected availability of blocks to other surgeons could help improve our backfill rates and we have seen that. So, these are just examples to sort of support the point that to me the digital strategy is having common governance, having common platforms, having a dedicated team but then really be solutions driven based on the top business priorities.

Paddy: Right. These are great examples of the real bottom line benefit and in the short term it’s not like you’re waiting for a long time to spend something up and waiting for the results. So, these are actually a great example. So, Manu one of the things that I do in my podcast is something got a lightning round where I ask for the top of my thoughts from my guests on a handful of emerging technologies. It doesn’t have to be necessarily what’s happening in your own health system but a general observation around the state of adoption of technology. First one is something that we’ve already talked about at length in your context. But I’d love to hear your views on what you see as adoption rate in the health system marketplace – cloud computing.

Manu: I mean you must have picked that up I’m favorable towards cloud computing. I think it’s cost effective; I think it provides flexibility. I think it can be more secure than on-prem if it is designed correctly and like we experience in our journey with AWS, it actually opened up to new innovative platforms to surround our EMR with. Prior to having this flexibility, I think you know if we had to try to do solution, we would have to set it up for the new servers and it would take months. Now we can basically try things within the click of a button, we can switch it off when we want to. So, I am overall very positive about the cloud as long as it is given the due diligence that it deserves to make sure that it is designed correctly and securely and use productively.

Paddy: Do you feel like your peers in the health system space by and large embraced cloud and they’re well on their journey towards migrating significant portions of their workload and getting into a hybrid kind of a model?

Manu: I don’t know. I mean I think there is more usage of SaaS solutions in the healthcare sector whether it’s cloud ERPs or service centers or call center solutions. I think the opportunity still exists for migration of on-prem assets to the cloud in the healthcare sector. I especially talk about this with anybody I can, and I would be a proponent for it.

Paddy: Right. Let’s move on to the next one. So, a lot of talk around this artificial intelligence, machine learning. Where are we in the healthcare space?

Manu: Well you know I think there’s a lot of attention with AI/ ML in the sort of image recognition. But I will say that I think there’s a ton of potential of AI/ML in what I call core operations and in reducing administrative burdens on clinicians. I’ll give you just a few examples that we have had some success with here. As you may know, before you got to have a few forms in line. So, got to have your consent form, you got to have your H&P form which is your history and physical form. And these forms come in all shapes. They’re called forms but they’re literally not forms. They’re just basically blocks of information that can come in and faxes and from different places and sometimes hand carried in. So, this is great for machine learning. Machine learning does well in recognizing you know images and NLPs are very powerful for this. We have implemented using TensorFlow for solution that runs on AWS with consent forms. We’ve been using a solution from Amazon called comprehend medical to detect H&P forms and they are now in production and they are saving hours and hours of time of nurses and other skilled resources that would have otherwise been looking for these forms. You know that’s an example of how I see machine learning playing a role on the operational and administrative side of it.

Paddy: Is your data and analytics organization are also part of your function or is it a standalone function?

Manu: It is part of our function.

Paddy: OK and clearly as part of your Amazon relationship it sounds like you are taking advantage of all of the advanced analytics capabilities that they offer as part of their cloud services. So, do you feel that in addition to just the cloud computing aspects of it which is scale and efficiency. You’re also getting the incremental benefit of all of their advanced tools if you will the analytical tools?

Manu: Yeah. It allows us to sort of try quickly, fail quickly, move on quickly or try quickly, succeed quickly, move on quickly. Because it has lowered the barrier of entry into bigger stacks of platforms which are otherwise not easy to get to. So that’s the beauty of it.

Paddy: Right. OK. The next one on my list – voice recognition.

Manu: Yeah, I think specifically in medical context voice recognition has great potential. So, understanding not just words but inferring context like taking out diagnosis, problem lists, and prescription lists with a high degree of confidence from unstructured data to convert that into structured data that can in turn then be fed into ML models. I think voice recognition and we are seeing solutions in that space. I think that’s to me I think the awesomeness of its potential because it can take this tons of knowledge that is locked in unstructured data and make it more structured.

Paddy: Right. The last one on my list here is something that’s kind of was in the news a bit in a big way last year but it seems to have fallen off the radar a little bit. I love to hear your thoughts on it – blockchain.

Manu: So, I’m high on cloud I don’t know what to say about blockchain. I am yet to see, I mean I’m Obviously open minded about it, but I’m yet to see a strong healthcare use case. I think I’m standing on the sideline observing it more that I’m not actively pursuing it as that’s how I would say.

Paddy: Yeah, you and several other CIOs I must add. OK. We’ve covered a fair amount of ground so far Manu and we’re almost coming up to the end of our time. Let me ask you something. What do you see as the top three challenges for a typical health system CIO today?

Manu: You know Paddy I can speak in context of my world. I think in my world demand and supply of IT services is one of my top challenges I would say. I think in general I think there’s three times the demand of what we can do. So even though we do hundreds of projects it just feels to me like it’s not enough. In the healthcare sort of business environment, you can’t expect to just keep adding resources to address that. So how do you enhance your productivity. How do you get more smarter in the way you work is something that I am constantly finding myself thinking about. We are doing things like trying to you know in IT worker space you know context switching is very costly. Programmers like to have dedicated space where they can work on things without disruptions that enhances focus. So, we are looking very carefully at how our unplanned work sometimes seeps into our work streams and I’m a bit of a fan of The Theory of Constraints. So, I try to look at it from the constraints perspective as to understand where our bottlenecks are. And we use methods like the Kanban boards to manage our weeps. And we look at it to try to synchronize our work across the department. All this to say that the challenge of demand and getting productivity enhanced is I would say at the top of my mind. Other two challenges, I would go back to interoperability. Save handoffs of patients between healthcare systems are when they arrive at a new place remains a challenge. And cybersecurity I would say is the third one. I spent a good portion of my time with my very capable CISO to deal with cybersecurity seems to be almost always under some kind of an attention or the other. So yeah those are the three demand, interoperability, and cybersecurity.

Paddy: All right. Very interesting and we didn’t talk much about cybersecurity. There’s probably a whole separate topic for a whole separate conversation. But as far as the first one is concerned, I imagine there’s a lot of technology consulting firms out there who love to come in and help you and I’m sure you have a lot of calls from them anyway. Just to round out our discussion today, want to talk about the digital health startup environment. You know we follow this a lot; this is kind of what we do as a firm in our digital transformation advisory practice. You know the broad numbers are that VCs are putting in about 10 billion a year give or take on funding digital health startups. The vast majority of them don’t go anywhere. Of course, the past week we saw a couple of big digital IPOs come out so that’s like a shot in the arm for the industry. What’s your sense of, what that whole landscape looks like today? Are you seeing real innovation coming out that you think you can integrate into your environment and accelerate your innovation. And if so what’s your advice to digital health startups looking to partner with the BIDCM in your digital journey?

Manu: Yeah I mean I think I get this question quite a bit. What I find myself end up telling folks is something actually that we talked at the top of this podcast which is paying attention to workflow is not enough to have a smart solution. It has to be put in the context of a very fast paced work pattern. The opportunity to impact lives is a short window where you can impact the decision making of a physician. So, I think thinking of the workflow part of it, I would suggest is one of my top advices I would also say that the less data you need for your solution the better. It’s an unfortunate advice to give. Data should be more fluid than it is today but that may or may not be the reality. So, if your solution depends on tons of data integration with major vendors, I think that’s a red flag to me. And then finally I would say that people and process matter as much as technology. I think innovation is not a technology only domain. So, creating new technically smart solutions is not the only way one can disrupt the space, the process side of it, and the people sign up for it it’s just as important.

Paddy: Yeah, I think that’s well said because people tend to conflate cool tech with digital health innovation and the people process the cultural side of it, the workflow integration. This is all the you know in the balls of how you actually make this thing happen very often. That tends to get overlooked. You also mentioned interoperability which is a big challenge. Even though in your environment you’re operating your own EHR system. So, for internal innovations I imagine it’s a lot easier for you to roll out innovation. But for someone else to come in and integrate with your environment I imagine it’s a little bit more of a challenge.

Manu: Yeah, indeed. I mean it is easier for us, almost think of it as a differentiator. And we do have APIs and we do integrate with a ton of _____[unclear] systems when we need to do so but I agree with everything you said.

Paddy: Fantastic. Manu it’s been such a pleasure speaking with you. I learned a lot and I’m sure our listeners are going to find this to be a fascinating conversation as well. Once again thank you so much for coming on the show and I look forward to staying in touch with you.

Manu: Thank you Paddy. Thank you for having 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

Manu serves as the Chief Information Officer for Beth Israel Deaconess Medical Center, a Harvard Medical School-affiliated academic medical center. In his current role, he is responsible for all IT matters pertaining to the academic medical center. He directs BIDMC’s “Center for IT Exploration” which works to adopt innovative analytics, mobile, cloud and AI/ ML solutions for operational efficiencies and to enhance the experience of BIDMC’s providers, patients, and staff.

Before joining BIDMC in 2014, Manu served as the Secretariat CIO for Massachusetts Executive Office of Health and Human Services where he led the state’s largest IT public portfolio. As Massachusetts’ state HIT coordinator, Manu led the development of the nation’s first medicaid funded statewide Health Information Exchange (HIE) known as “MassHIWay” which has now delivered over 200 million healthcare transactions since its inception.

Manu was recognized by Computer World as one of the top “100 Premier IT Leaders” in the world and by New England HIMSS as “The CIO of the Year” for 2014. Manu has an engineering degree from Indian Institute of Technology, an MBA from Boston University, and an MPA from Harvard Kennedy School.

About the host

Paddy is the co-author of Healthcare Digital Transformation – How Consumerism, Technology and Pandemic are Accelerating the Future (Taylor & Francis, Aug 2020), along with Edward W. Marx. Paddy is also the author of the best-selling book The Big Unlock – Harnessing Data and Growing Digital Health Businesses in a Value-based Care Era (Archway Publishing, 2017). He is the host of the highly subscribed The Big Unlock podcast on digital transformation in healthcare featuring C-level executives from the healthcare and technology sectors. He is widely published and has a by-lined column in CIO Magazine and other respected industry publications.

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