Bill Russell: 00:00 welcome to this week and health it influence where we discussed the influence of technology on health with people who are making it happen. My name is Bill Russell, recovering healthcare, CIO and creator of this week in health it a set of podcasts and videos dedicated to developing the next generation of health it leaders, it's podcast is brought to you by health lyrics. Have a struggling healthcare project. You need to go, well let's talk. Visit health lyrics.com to schedule your free consultation. Now we we rejoin a conversation, which we started last week with Dr Andrew Rosenberg's, CIO of Michigan medicine. The topic is experience. Last week we took a look at the uh, internal customer of health it and their experience. This week we're going to take a look at the external customer of healthcare and their experience. Now we resume this conversation already in progress. Hope you enjoy.

Bill Russell: 00:54 All right, so that's the internal customer and we've spent, uh, spent a lot of time there. I just want to make sure we're okay for time. Are we okay for time? Okay, great. So we're going to have into consumer direction. And I guess you have to start with the basic question, which is, um, you know, we're seeing the word consumer more and more with regard to health services. Uh, do you think that's accurate today or do do you think we have, uh, well first of all, do you think it's accurate? And then second, do you think it's good for healthcare to have consumers? I've heard physicians say to me, I, you know, I don't want to have consumers cause sometimes I have to say very challenging, very difficult things to them. And you know, they might choose to go to another doctor just because I said, hey, you know, you've got, you have to do these things. And you know, it's to some extent having that tight relationship, uh, enables you to say the hard things when you need to say the hard things and whatnot. So do you think it's accurate and do you think it's good for healthcare?

Andrew Rosenber: 01:51 You know, the, the, the current consumer discussion is, I think you were alluding to it also. Um, similar to the discussion of client. You call a patient to patient or a client that, um, I heard a lot through medical school in the late eighties and early nineties. And so I would argue this, I would argue the intent behind consumerism and that discussion is incredibly important. And I would say most of us are spending time thinking about that. At the same time, I think we're probably overplaying its importance and I'm sure that there are other people who would love to disagree. The reason is that there are parts of healthcare that are elastic and parts that are completely inelastic. You have a broken bone, you're just a very different consumer than when you have a broken down car. The more appropriate analogy may be a broken down car that your daughter is in on the highway at night in the rain.

Andrew Rosenber: 02:52 Right? You know, and so your behaviors are going to be incredibly different about consumerism based on the underlying situation. And so I think we, we hear a lot about consumerism for the more elastic part of healthcare. The, the primary care when you're not really that sick or the, um, uh, the lifestyle care, I don't want to diminish when I say lifestyle, but aesthetics or things like that. And then there are other parts that why they may not originally, um, come across as, uh, inelastic, uh, um, physical therapy of voice therapy when it really impacts your job. When you're a teacher, a pilot, a professor, and you can't get your words out. Going to the speech pathologist is incredibly important. And so I don't think that the latest mobile app that allows the consumer to pick and choose and disrupt healthcare is going to happen as quickly as some people may think.

Andrew Rosenber: 04:05 I saw one vendor discussed the fact that millennials today have no loyalty for their doctors or their health systems. And I suspect part of that is accurate. So it could be just an age difference. But when people do become sick or develop a chronic disease or develop one of those inelastic items that I've talked about, I don't think consumerism, I don't think people with really bad abdominal pain that might be appendicitis or might be the onset of ulcerative colitis will tend to look for the least expensive five star clinic two miles from their home where they can drive through. You know, we can just take this analogy so far and yet at the same time when we talk about patient experience, family engagement, I think there's some really good things there that in the past, certainly during my training, we never thought about who cares what the food is, you're in the hospital. So I think there are elements of this that are very good for the overall experience, but I think we overplay it.

Bill Russell: 05:10 So let's, let's go back and forth a little bit on this because it's, I mean, the point you bring up are really a really good and really, really fascinating to me when I think about, uh, the consumer is it's access method, cost, structure and experience and your right. So if I have something, um, am I going to go to the, you know, where am I going to go? Now what has traditionally happened is the healthcare system has said primary care physician, you start there and then we will sort of branch out from there. And the first thing we're sort of seeing go away is that primary care physician is the entryway into the health system right now. The entryway into the health system, right, wrong or indifferent a lot of times is the Ed and we don't want it to be the ED. So then we stand up these urgent care clinics around the community.

Bill Russell: 06:01 And so then that is sort of a, I dunno, it's another form of Ed if you will, but we ended up going in there because the, the model that you've given me as a, as a, as a consumer of health, I, I don't like, I mean I models that the primary care, so I have to call my primary care doc and they go, well, it's your first visit. You know, we, we only do first visits every Tuesday's a third Tuesday of the month. So we'll see you in, you know, two months for your first visit. And I'm like, well, I got, I got a broken arm. You know, can I, I, that's bad example. But you get the idea. I mean, the primary care, um, my daughter needed a primary care in Missouri. She called and they were like, and literally first is it two months out? And she's like, what the heck am I supposed to do for two months? That's the silliest thing going. And so she went to the urgent care clinic.

Andrew Rosenber: 06:58 That's a great example. Let's just take that for one second. Bill. That's a great example where consumerism really has a place because it is starting to appropriately modify hundreds of years of tradition in healthcare. And that to me is a superb example where better data and the apps that deliver those data would allow your daughter or someone like that to see a very good, um, physician or provider in a fraction of that time. So for example, the whole point of, um, self scheduling is a real sea change for a lot of providers. In fact, we're still struggling with that ourselves because we would, I would say we have, I'm gonna make this up about a third of our faculty who are really strongly proponents, but two thirds aren't. And the reasons are complex. Part of it is because we have a very strong academic faculty at the University of Michigan.

Andrew Rosenber: 08:00 And so some of these people, they're very dedicated, but they're in the lab or their teaching or they're doing something else. Part of it is tradition. A part of it among specialists is, um, you know, the complexity of what they do. But the consumerism part that you started with is a good pressure to modify some of those age old things. You should not have to wait, wait two months to see a primary care provider. Uh, one of my best friends, uh, did have a hurt arm in Baltimore and he called me up and he said, I can't believe that all the eds in Baltimore don't have wait times available by apps. So I could go to the Ed with the least wait time. And he said, it's because you're all competing with each other and you don't want to share the data. And I said, actually, I don't think it's even that, by the way. Uh, I think eds would love to decompress their wait time. I think it's, we've just not sat down to talk about how we could share those data because technically we could, I don't, I don't see it as a competitive process. I think it's, it's really a priority issue, but that that would be a very positive step that consumerism takes. So I do think those are good examples.

Bill Russell: 09:13 Um, it's interesting. So let's just take the Ed, um, you know, cause uh, the head of Walmart's care delivery, essentially I was speaking at a large conference and she said, I want you all to take that down. You don't want my people going into your ed anyway. So stop telling them it's five minutes at this ed you want, you want them going somewhere else. So stop encouraging them to go there. We don't want them to go there either. Um, and it's, it's Kinda crazy cause we, one of the health systems I did some work with, they had an ED and across the hall they had an urgent care clinic. And as you know, the cost structures, even if it was across the hall, are completely different. I had a conversation with a CIO, who said, we had the ed and we had a person sort of standing at the door who said, you know, ask them what their thing was and said if you'd like, you can do a telehealth visit in that room right over there with a physician.

Bill Russell: 10:07 And you know, the cost would go way down. The wait time would be a lot less. And uh, and I think it was, I forget the percentage, but it wasn't, it wasn't an insignificant percentage that said, yeah, all right, if I could talk to a doctor quicker, I'll go sit and do the telehealth visit right over there as opposed to going to the ED. Um, there's, there's so many, there's so many things that are just from a, from a consumer standpoint, let's take it from a consumer standpoint, you just look at it and go, I don't understand. I don't understand why that urgent care one door over from the Ed costs that much less. I don't understand why I can do telehealth. Uh, if I go to the Ed, I can do telehealth there, but I can't do it from my home. There. There seems to be so many things that the consumer is looking at it going, they say the millennials and the millennials do the millennials look at it and just go, I don't understand health care at all.

Bill Russell: 11:04 If this is the, this is the way it is. I just don't get it. And as you say, it's a hundred years of, of practice and it's a hundred years of, of education and those kinds of things and cultures change very slowly. And especially cultures with this much back end infrastructure and this many backend workflows and processes and regulations and security and compliance, they don't change overnight. So it is, it is a slow process. But on the flip side, there's an awful lot of new entrants coming in saying, that's fine. You can, you guys move as slow as you want. We're going to just start picking them off clients one by one, uh, from around the edges. And, and as my friend John Manis said in last week's show, um, you know, they're not looking to take the low margin, a high risk business, they're just going to take the high marsh and low risk a business until we're left with a shell of what we used to have that probably, you know, at Michigan or cedars or Mayo. But it may happen at some of the other health systems.

Andrew Rosenber: 12:09 Right. And I guess what I'm saying is that the consumerism ideas are great. John and I as you know, talk a lot about this. I happen to think that it again, you, you have to ask what is it that you're talking about? Um, I don't think the analogies of, um, low end steel production ultimately, you know, being taken away lead to the high end, really high margin steel production like in some other industries. Some of those examples that are then applied to health care are a bit difficult. I think that there are aspects where consumerism has made enormous difference. Since when I was training, we had wards with 10 to 12 patients in them. Uh, when I was done with training, we still had rooms with at least two patients in them. Now it'd be hard to find a hospital that's being built without private rooms, whether therefore, uh, infection control but it's much, they're being built for the patient engagement and patient experience.

Andrew Rosenber: 13:13 Even that conversation is getting old fashioned. When you think about the ability, what we really want to do is move patients back to be taken care of at home and with increasing sensors, technology, audio, visual, uh, automation, robotics, drones and all of these kinds of tools. We're going to start being able to do things at home that we could never do for awhile because we needed the monitoring, the rapid response, the precision of, um, different tools that could only be available in hospitals that are now being used at home. This is all part of both consumerism, but I only say this because as we shift some of these cases to AI, mobile devices, urgent care centers, other types of providers, what I think it does is it also frees up time and effort to do the more complex things that we don't do or that we don't do as well.

Andrew Rosenber: 14:09 Uh, we, we know that virtual care is really just care. Uh, the ability to provide tele mental health, um, store and forward images from more complex dermatology, radiology, pathology, all of those things are not virtual care. Those are just care. And I think as we move those items, some of which are perhaps more influenced by consumerism but others which are, um, influenced by the funding models. What we're really going to have is not our lunch taken away from us as some people will say. I think what it's gonna do, it's gonna free up new opportunities that right now we're just not even doing because we're spending our time on some of this other work. But that's going to be one of those endless debates that people will love to have.

Bill Russell: 15:00 I love, I love having these conversations with you because I think it is the conversations that are going to move this forward. I think it's the, I think it's the interactions, it's the, it's the discussions around, um, just what can we actually do, what can we accomplish? Cause there's nobody, there's nobody on either side of this debate that sitting there and gone, yeah. You know, we don't want, we know we don't want health care to change. Almost everyone's sitting there going, we know it's going to change.

Andrew Rosenber: 15:28 Yeah. But my point that I've made to you before, which I, I still very strongly feel is there's just so much that non-healthcare examples can then be applied to healthcare. And that's not a luddite and that's not a defensive posture. And I think we are having those kinds of conversations. You know, millennials are used to having this, this, this at all, at the touch of their buttons. So they're going to want it for health care. Some of it's true, but you see these examples already starting. Some of it is probably slowed down more by the funding models and anything else. Not a desire to do it, but a lot of it I argue is just not that transferrable to healthcare. And that's where we need to be a little careful that the fear of missing out, the desire to not look like a Luddite the need to always show the cutting edge health care is different.

Andrew Rosenber: 16:26 And by the way, it's not dissimilar in some of the other work I do around academic, um, it support the, the idea of the flipped classroom, the idea that you can see a video and then go to classroom to do your homework is a interesting idea. And in some areas in education that is happening and happening more and more, but that doesn't mean that all education now gets flipped. It's just part of in where it makes sense to do it. And what kind of education you're talking about. Very high level. Graduate Education requires a very different type than a technical training. And so we have to be careful with, when we talk about consumerism and there's an app for it, when I say, you know, how are you going to do it? How are you going to pay for it? How are you going to secure it?

Andrew Rosenber: 17:16 I would also add and what problem are you really solving with it that is really amenable to that technology or that um, patient, um, expectation and it gets more complicated. So bottom line for me is I see examples of consumerism everywhere. I would argue like I did virtual care, virtual health, telehealth, consumerism is really just how we do healthcare. And while I think we can get examples from other industries, you know, we're at a, you and I where we heard a chief innovation officer talk about the experience of a huge entertainment company and applied to a very well known health system. That's, that's good. But where some of that service offerings of a huge entertainment company I think are great. And that's why I go to that entertainment par. Only parts of those really can be applied to a A patient with advanced dementia who also has three very significant chronic diseases and whose family is very conflicted over the care, you know, and that's the patient population ages. Some of these items that we talk about, millennials do not transfer over to an aging population. So we have to be thoughtful what we mean by these terms, like consumerism.

Bill Russell: 18:43 Yeah. Well, and the other thing is, I mean, you talk about it and you lay it out really well in terms of the complexity. Um, do we just say, you know, we're consumers, I'm in healthcare and it sounds like it's just one big bucket, but we all know that healthcare is a hundred businesses and even within the four walls of a health system, it's a hundred businesses that your managing and running, it's the reason you have 600 applications. It's the reason you have so many specialists in so many different areas, so many care delivery mechanisms. It's why you're looking at home based care, you're looking at, uh, clinics, you're looking at a, I mean, there it's a hundred different businesses. And so when we, one of the ways we get in trouble as we start talking about consumerism in healthcare, like it's going to be applied to all hundred businesses the same way across the board.

Bill Russell: 19:30 And the reality is that people that are making progress and really doing well in this are stepping back and going, okay, let's identify the, you know, the three patient experiences we're going to tackle first and then we're going to add two more. And then we're going to, if they're not saying we're going to become a consumer business tomorrow overnight, uh, they're, they're really sort of wading into it thoughtfully and saying what areas will, um, and, and listening to their consumers what, what, what areas will benefit the most and what are the consumers really looking for that we can offer? And what are the consumers looking for that potentially they don't even understand what they're asking for because the complexity of healthcare is such that they, they may not want what they're even asking for.

Andrew Rosenber: 20:16 I guess. Let me give you two quick examples. Um, one that I really like is a few CEO's and I were at a small meeting and accompany that. It produced an APP that was actually pretty cool while the CTO of the company was talking. I literally downloaded the APP, signed in, created a new user account, logged in. And actually started using it all within about 10 minutes. It was a pretty sweet design and it essentially would use AI algorithms to take you down a series of questions and then put you in touch with an actual clinician. So not bad. But when I asked what was the business model, they said, well, millennials are, um, are disloyal or not loyal. They want to disrupt healthcare. They don't feel that they need to have their own doctor, let alone their health systems. So we're going to try to disrupt healthcare classic, you know, phrase, uh, for you know, $25 a visit and we know they're going to pay it.

Andrew Rosenber: 21:20 Something like that then. Okay. But what I said was, you know, whether a millennial or an individual is not initially associated with the physician or a health system, their health plan, uh, where health healthcare financing is going, or when they do get older, they do get a chronic disease, they do get ill, they probably will get hooked into some form of some integrated network somehow. And I don't think the platform is a standalone will disrupt healthcare, but the platform for those health systems to still do new types of care, to engage with patients, that consumerism idea, I thought it was actually a really great platform that wasn't their business models. So when we talk about consumerism, we again have to talk about what's the business model that either the vendor or we're looking for. The, the other one was an example you gave a little bit earlier.

Andrew Rosenber: 22:16 Um, like I said before, hospitals, clinics, providers, new technologies are I would say more focused on the patient experience than ever before. And we're, we can find this artful and I think it's art. It's not science at this point. Approach to those examples that are standard or standard or amenable to being standardized. You talked about, you know, maybe pick three use cases. Well, right now those three use cases could be totally different for a variety of patients with the exact same condition based on their age, their financing, their education, uh, you know, dozens of, of reasons. The art to It will be where are those robust, those standard approaches robust to the patient and their setting. And I would argue that it's just the attention to the consumer, to the patient, to the family experience in and of itself. That probably is the starting point. And you know, think about CIO's who've been doing this for more than 10 years. They never had these discussions, I would say, or very rarely. Um, now we're having these discussions frequently. That's a, that's fundamental change. The question is what are the models that are robust and then what are those that are very, very specific that an individual or a small unit will find helpful and others won't. That's part of the conversation.

Bill Russell: 23:58 How much of your time, last question, I promise, but how much of your time is spent on technology today and how much of your time is spent on these kinds of questions, these kinds of discussions, culture, people, um, workflow, those kinds of things.

Andrew Rosenber: 24:14 I think I'm combining them. I mean, that example I gave earlier about the storage, that to me is as much a question about how do we partner? I'm talking about this massive amount of storage requirements to do types of basic science in this case, but over time this is going to be more and more going into operations. That's as much a question about how do we find truly new technologies as it is about one or two individual faculties labs. So I use that need. We have faculty who are asking for that now to stimulate a much more interesting strategic conversations. So I don't view it as technology or strategy or integration or things like that. I tend to find those really good examples. Oh, another one again, I'm just picking things that are happening this week. I could, I could do this for hours, audio, visual, audio visuals all over the place right now.

Andrew Rosenber: 25:15 And one of them, to get back to one of your themes about consumerism are our bedside engagement tools are a family networks, whether it's getwellnetwork or epic bedside or any dozens of these. Um, that gets into a discussion about what do we mean by Av? We put TV screens up, we put flat screens for digital signage, we put whiteboards in the Olr, we have classrooms. And we have conference rooms, we have monitor capture, we have lecture capture, we have evaluation tools and all of those get wrapped up into a v. So what do we even mean by that? Just getting our hands around what that means to run, to replace, let alone to innovate in it has some very pragmatic side. I have to keep the trains running but then they also get into how those tools that I just mentioned play into some of the new areas like we've been talking about consumerization, patient engagement, efficiency, real time analytics. I tend to look for use cases to wrap all these discussions and because they tend to be so integrated anyway, separating them out is, is um, is a, is a mistake. If anything, the problem is trying to not over connect dots cause he also sometimes just have to execute and get some things done.

Bill Russell: 26:36 I had a conversation with the CIO. They said, where did Avy report in your organization? I'm like, construction. He's like, you're kidding. I'm like, no I kid you not. It report it into construction. They have a little av team and every new piece of Av that went in anywhere was was them. I'm like, you guys walk. Did that work for you? I'm like, oh, not at all. It didn't work at all. I mean, every time I walked into a room, it didn't work

Andrew Rosenber: 27:02 and this is exactly it. We could have a hundred CIOs and other it professionals on the phone and we would have almost the identical experience because that's exactly what it is for us. Facilities we'll put in some, but now not even all of those parts. We'll do the networking. They'll do the conduit. They all attach the flat scream or another group will do that. Then in this is where you see it play out, who's going to pay for the replacement? We're dealing with that right now with one of our very advanced auditoriums that has probably $1 million worth of advanced Av in it. It's now 10 years old. No one knows who's going to replace it. No one owns it, and I only bring that up because your question about how much has technology and how much is operations. Well that's a, that's a classic problem any CIO has to deal with.

Andrew Rosenber: 27:52 But where do you now attach those kinds of examples to something new like, um, way point finding and family education in order to turn the hospital into a staging area for care at home. Because what you really want is to not stay in the hospital for any length of time. You want people to efficiently get to where they need, get all the support they need so that they can be now taken care of at home. I can attach some of those av discussions even into something that is as cutting edge as turning a hospital into a staging platform for care at home.

Bill Russell: 28:34 That's interesting. That's fantastic. Well, thank you for your time. It's a, I really appreciate it. Um, is there a way for people to follow you? I mean, do you do, I mean, you have a full time job. I'm finding more and more as I ask these questions of CIO's and they just look at me like, when would I have time to hang out on Twitter?

Andrew Rosenber: 28:52 Um, no, I, I wish I did had, I don't right now for really those reasons. So no, I am, I'm, I am not at all disrespectful of it, but I am occasionally on Linkedin, my email arosen@umich.edu of courses always available to anyone. But, um,

Bill Russell: 29:12 yeah. And, and, and you, you teach, do you teach as well?

Andrew Rosenber: 29:16 Yeah. Now I'm faculty at the University of Michigan in the medical school as well. Yeah.

Bill Russell: 29:20 Yeah. So it's, it's not, it's not like you're not out there teaching. It's just a matter of, you know, where you have to choose, where you can engage, otherwise you'd never get to see your family.

Andrew Rosenber: 29:29 And I can be guests on great. You know, great outlets like yours. So

Bill Russell: 29:33 I appreciate it. It's a shameless plug for you, by the way. Well, I appreciate it. And we'll see you again this year at the Becker's conference, I assume. Yeah, yeah. Fantastic. That's a shameless plug for you.

Andrew Rosenber: 29:43 Right now. We're, we're going to be, I'm going to try to be taking the con to all things visionary in it I'm, I'm hoping to stimulate the debate of all the great things we want to do and then how are you going to pay for it? How are you going to secure it? How are you going to do that as well as all the other things you have to do, right? That's what we all face,

Bill Russell: 30:03 but, but you're not taking the con because that's where you live. You live on both sides of that.

Andrew Rosenber: 30:08 I'm going to be the Darth Vader of CIOs.

Bill Russell: 30:13 That should be a fun cover. I'm looking forward to that and that's in Chicago in the fall, I believe. So looking forward to this show is production of This Week in Health It for more great content. You can check out the website at thisweekinhealthit.com or the youtube channel at thisweekinhealthit.com/video. Thanks for listening. That's all for now.