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 Welcome to this Week in Health It where we discuss the news, information and emerging thought with leaders from across the healthcare industry. This is episode number 45. This week we have. More discussions from the Chime fall Forum in San Diego, where Tom Stafford and Bill Hudson join us. Tom Stafford from Halifax Health and Bill Hudson from John Muir.

These two gentlemen, we, uh, take some time to go into, uh, A deep dive into technology questions. Hope you enjoy. Great. I'm Bill Hudson. I'm the associate c i o at John Muir Health. I'm responsible for IT operations. Awesome. So how long have you been there? Uh, about two and a half years. And prior to that, prior to that, I ran healthcare strategy for VMware.

And prior to that I was a C T O at, um, Kettering in Ohio. Yeah. And that's, we, uh, ran in, ran into each other when you were on VMware. So I, I'm gonna focus in on like . Really the technology track with you? Sure. Everybody I've interviewed so far here wants to talk about culture 'cause it's, I think one, it's potentially an easier topic to talk about right now.

Um, but the, the technology track's pretty interesting. So we, uh, when we ran into each other, we were doing a large, uh, when I was a C I O for a health system. We were doing a large cloud migration, and, uh, VMware was obviously a part of that. Um, what are, what are some of the things you're, you're thinking about or doing, uh, these days with regard to your technology stack at, uh, at, uh, John Muir?

I. So, you know, one of the things that, um, I did when I, I got to John Muir is, you know, we started talking to the technology team and looked at what they had, and they had, they've done a great job over the years and, you know, they've got a, an impressive team. They great, great data center. And, um, I looked at 'em and I said, you know, guys, I, I, I don't think that running a data center is necessarily strategic to healthcare.

And in fact, I, I don't think data center management is our core competency and nor do I think it should be. Um, I think we need to continue to focus on orchestration application management, enabling new users, um, and focus on, you know, the, the growing automation and integration of technology into the IT and the care processes.

And, you know, that means that maybe we don't rack and stack servers, we don't put memory chips in 'em. And I, I wanna be cloud, I wanna be cloud first. Um, and I challenged them. I said, you know, in five years I'd like the data center to fit in my office. You know, this is not, this is not something I think is, is, is rocket science.

I think this is doable and uh, I think it's gonna make So you have things square foot office? Is that what I have a huge office. No , no, I, we're in healthcare. I have a, I have a, a normal sized, normal sized office. But you know, it's, I, you know, I, I call it, it's our, there's our big, hairy, audacious goal and, you know, two and a half years later, You know, we've reduced the overall footprint of the primary data center by about 50% in terms of, of Compute stack.

In fact, I probably have more blanks in my data center right now than I have servers in the data center. Um, you know, to keep the, the keep, keep keep and manage the cooling. But, you know, it's been, um, it's been a little bit of a shift and so, you know, we had to do a, uh, bring some folks along and we had to, um, get the organization used to thinking Cloud first.

And, and you know, today, two and a half years later, it is . You know, we've, we've gone through the process of tiering all of our applications, you know, tier one through three to figure out how, what's the best right place for those applications. And, um, it's not like we went forward and said, okay, we're gonna move everything off the floor today.

Right? It's when we get to natural break points, when it makes sense when we're moving to a. A new version of the application or we're moving to a, um, a new iteration of an application. Echo for credentialing, for example, is something we're looking at right now. Um, you know, echo is something we've traditionally run on, on-prem and a lot of healthcare organizations run Echo on-prem.

You know, we're actively looking, um, at moving to the cloud model with Echo. Now, we won't run that in our data center. We won't run that in a cloud. Cloud data, our, one of our cloud data centers, we'll run that in. We'll echo when we'll get, we'll get credentialing as a service and we're gonna, that's gonna allow us to do some things we've never done before.

Um, potentially we're still working on the contract. Um, and one of those things will allow us to do is be able to integrate, um, our credentialing system with our internet. And so we do physician scheduling rather than have to maintain a separate database for that. We're gonna get it right from the source and it's gonna allow us to do some really cool things that we haven't done before.

And that's one of the big advantages of taking a cloud strategy is . Um, the, the ability to integrate applications, the ability for us to focus on our core has been, has been really, uh, a big deal. But, you know, one of the things we've, um, done is we've looked at our, um, little application stack and we looked at things that make sense to, to move off-prem and those things that make sense to move off-prem today.

Things that are lightly utilized, um, or great candidates move off, off prem, um, gets organization good experience in using those applications and securing those applications. And managing those applications. Um, and then we also look at things that are another other great fix. Things like disaster recovery.

You know, running an application like Epic full-time in the cloud today is, is not cost effective. Um, it is probably on the horizon of things as costs continue to come down for that, for that medium. Um, but Dr. In the Cloud is a wonderful solution for something like, um, for Epic or for any of your systems because, You know, you're running them on a partial basis.

You're only paying for the stuff that you're using. So test systems, demo systems, you know, development systems are all great candidates and those are the kinds of things we've been been focusing on in terms of where we're going. It's interesting 'cause I think people hear us talk about the cloud and they think we oversimplify it, but, but generally, I mean, we've talked about this, um, before, I mean there's, when we talk about the cloud, we're talking about there, there's gonna be legacy cloud.

You can run things on a VMware cloud or an a w s cloud, you can do, uh, as a service. So you could do, uh, uh, cloud native application. You could do all sorts of, when we say cloud, it's, it's, it's a bunch of different architectures, but it still requires architecture. 'cause you can't like move your data into one data center over here and one data center over here.

Exactly. You've gotta start thinking through architecture. I know it's a dirty word in a lot of areas, but you really do have to start thinking about where's this gonna reside? What are the hooks into this data? How are we gonna be moving it around? Um, are, or do you spend a lot of time on the, I assume you spend a lot of time on workflows.

Do you spend a lot of time on the data architecture to So the answer is yes. Um, so to, to kind of, absolutely. And I think one of the things I think is, is really important is. Is if you have weaknesses in your, in your systems or weaknesses in your processes or weaknesses in your organizational alignment or governance, um, you, you take a cloud first model, you're gonna find those pretty quick.

Um, yeah, and, and, and I think part of this is about, and operational alignment and communicating to make sure everybody understands. What we're doing, what we're getting into, why we're getting into it. Um, but it also requires an intense amount of orchestration to make sure that we're getting all the pieces and parts put together, right?

The architecture of it, if you'll, right. So if I, if I take a, a, a haphazard approach to how I'm gonna manage cloud, and cloud by the way means a lot of different things, a lot of different people. And you think you called it out very well, is that it? It, it is a lot of different things and it's not just about securing stuff within

For all intents and purposes, my four walls of my organization where I can put my arms around it, I can put a motor around it, I can guard it, um, and I can, and I have complete total control over it. I have to have the ability to extend my virtual control, um, to a, to a variety of different places. So I have

Some stuff sitting in Office 365 with Microsoft, right? So I've got my email out there and we are looking at doing some stuff with them potentially around bi. Um, you know, we've got, um, we've got data right now. We've, we've moved to Workday, so H c M and E R P are sitting in, in a workday, um, environment. Um, we're looking at some, we're clinic supply chain right now that'll, that'll be in that environment and those applications have been on-prem will go away.

I'll say, all of a sudden I've got three different locations for getting data. One third of our, one third of our clinical, um, providers, one third of our providers are, are community Connect users. Okay? So we've got the, um, to our surprise a little bit. Epic came out during one of the last reviews and said, you know, you guys are the, the fifth largest community connect site.

And we're a community hospital in, in East Bay and in San Francisco. And we're like, well, you know, you mean in terms of percentage providers towards our population? And no, just in terms of total transaction volume, which was, it was kind of eye-opening for us. And you realize that, you know, the good part of what we're doing around our, IT is providing now service to organizations that are outside of our four walls, outside of our control that we're offering service to, that are also kind of cloud connected to us.

And so you have to have a strategy around . How you can provide those services and secure those services. And so, you know, we, we, we looked for a security platform that we could manage across those layers and an orchestration platform we could manage across those. Uh, right now, VMware's a partner in terms of how we're managing workloads, but you know, we're also, we also have stuff sitting in, in, um, Microsoft right now.

And we're also looking at a growing number of . Uh, our application providers who have decided that they like the idea of cloud because it provides a nice little annuity stream for them. And so they got a number of those guys who are jumping into that space and saying, Hey, we're gonna offer you X as a service, which is awesome.

But then we have to go back and look at it and say, are these guys really ready for this? You know, when I look at a, at one of these contracts and, you know, they're offering, you know, 99% uptime and on a monthly basis and we won't take, and that's only during what we consider core business hours. And, you know, and the extent and the example around what we're trying to do with Echo, for example, um, you know, that's.

That's an integration for serving potentially, um, um, our intranet to provide access to our patients about who our physicians are, where they've studied their credentials. Um, so we have one database, you know, the ability for me to, to have that go down at, you know, 10 o'clock at night when someone's potentially sick and looking for a physician is not a good thing.

So, um, we have to help to a large extent, some of these guys are just coming into this space and they're, and they're moving into this, help them understand. You know, what the requirements we have, um, as our business, things that you and I have gotten used to doing over our, our careers that these guys are just kind of stepping into it and they have to realize they have to support to a different level.

Do, do you think? And so the buzzword of the buzzword over the next 24 months, I think's gonna be DevOps, not that DevOps is new, but . Healthcare is, healthcare is starting to acknowledge that DevOps exists. . Um, I mean, are you, do you think we're going to see that kind of model, uh, really start to permeate the infrastructure side at least of the, uh, Of health it.

So I, I do, um, I do for a variety of reasons. And you know, part of it is I think the lions are starting to blur and I think cloud's helping us to, you know, cloud first strategies for a large extent are helping us to do that to a certain extent. Um, and we're getting, you know, even with Epic, for example, we're getting into.

A quarterly upgrade cadence with Epic. And it's not just for Sus anymore, it's for, you know, for, for, for new functionality on a quarterly basis. And, you know, unless that's gonna consume us, you know, totally consume us, we have to, to adopt a, a methodology that's much more agile, um, and helps us, you know, move down the road, no pun intended, but it helps us move down that road, uh, much quicker because I can't afford to

To have a huge team that's spending nine months of the year doing nothing but upgrade. Right. I've gotta get that down quick so it's fast, it's iterative, and then it has to include robust testing. It has to include our end users and you know, DevOps is a good framework. The problem that I have with the DevOps approach is everyone wants to go down this agile path, and we've been waterfall in healthcare for so long.

But for good reason. And you know, when you make a, when Apple, you know, has an app or um, an apple's uh, application in their ecosystem, you know, that's the Marriott app, you know, is gonna update new functionality and they update it and, you know, if something breaks in it, you know, the worst thing that happens is a traveler has to call somebody.

Or, you know, they check in manually versus checking on their phone or, you know, they can go to a web-based app and try to do it this way when something doesn't work in healthcare, you know, potentially someone's not getting an order for something that they need. Um, and so the level of testing required, um, is, is much more strenuous than it would be in a normal, agile, agile environment.

So you have to figure out some way to meet a happy middle between . The, the, the detailed rigor of testing in a waterfall environment plus the agile ongoing test as you build it approach in, in a, in a more of a, an agile methodology. And we have to merge those two things. And so I think we will do it, but I think we'll find a, uh, a little bit of a middle ground where it comes to testing.

And we were talking before we got on here of, uh, a lot of healthcare organizations don't have the infrastructure to even. Do that kind of, that kind of testing. I was, uh, again, doing consulting, traveling around a lot of it, a lot of healthcare environments have a production e h R environment, but don't have dev or test.

Um, how, how important is that to just make that investment, get dev test prod in place so that you can, you, you can start to be more agile, but also do the, do the right. Testing before you put things into production? You know, I, I think it's incredibly important. You know, I think if you look at it, um, you know, even 10 years ago, you know, the number of integrated systems was high.

Um, but you looked at your core systems and it was a, you know, it was a, it was a few things, you know, you had to test on a regular basis. You didn't have duplicates of necessarily everything, which was, um, to some extent, you know, problematic when you do testing. But this day, you know, everything's so

Tightly fitted against each other and, and integrated at such a tight level. You have to have those, those, those systems that you can, that you can test on, and you have to be able to manage them, um, in a, in a, in a good and proper way. And I'll, I'll give you a good extent, uh, a good example. Um, you know, having a test environment for.

New code that's being developed is not as, is not the same thing as having a test environment, right? It's pristine. That's a copy of prod, right? That once a last minute fixed test through, yeah, we say dev test stage production. You have to have some kind of certification environment and so that's a whole methodology and you start looking at it.

It's not one extra environment. It's probably two or three extra environments. And I think for the most part, um, you know, most folks that have gone through the implementation, you know, in the days of r in the last 2009, a lot of those guys have gone down that path, um, of implementing 'em. But I, I think it's important to make sure that, um, we maintain the rigor in terms of how we support them to make sure that those environments can stay consistent.

Um, that the certification environment is in fact representative purchased in your production environment so that when you do have something to come through as a last minute, what you're testing is actually a against something that you know is, um, know it's in use and then, and everybody goes, oh, I'm sure it's gonna be fine.

And you know, 99% of the time you're gonna be completely fine. And I can tell you, you know, over my career, there's only been probably two or three times where. And the certification environment prevented us from moving an Air Ford. And people look at that and go, well, two or three times, was it worth it?

And, you know, yeah, yeah. Well, my, my comment is, yeah, it absolutely is worth it. In one case, it was, um, it, it affected, um, a revenue cycle issue and in another case it affected the clinical care issue. And I can't honestly remember the third one was, but that's a, um, Yeah, absolutely. That's a, um, something that we have to, you know, I think we have to put a, a little bit of a attention to and make sure we're, we're, we're putting some, you, I haven't, haven't done the HR in the cloud yet, but in r in the cloud environment.

Do you get those, those different levels? So we, we're not running, we're not running HR in the cloud right now. We are, we have a partnership with a, uh, A hosting provider that's, um, hosting our dr, we are actively looking at doing it in the cloud. Um, and when we go that direction, it will be, we will have that, I think people think is, oh, I'm gonna outsource it.

And we moved, we moved our E H R to the cloud. We, we have Cerner in the cloud. We have Epic in the cloud, but you still have to. You, I mean, you still have to certify the security and you still have to cer certify the, the, uh, new code that's coming into your environment. Yeah. You, and in fact, I mean, it boils down to your responsibility is even more about application and functionality and workflow than it's ever been.

And I think making sure that, um, making sure that you manage that and pay attention to that, you're not be getting that responsibility. You still have that responsibility. Um, if you don't do it, you're gonna get bit by something at some point. Um, so is there, last question here. So is there a technology that you are keeping your eye on that's you're saying, Hey, you know, in the next three to five years, I, I think there's gonna be a lot of movement in this area.

Well, I, you know, I, I think we're, you know, along the subject of cloud. You know, I think we talked earlier, I think there's a number of things that make a lot of sense for us from a cloud standpoint. Disaster recovery in a cloud is a, is a great use case for cloud tech. Um, I think that we're gonna see, um, the cost of cloud computing and the capabilities for cloud computing decrease.

So, As the cost decreases, the, the capabilities are gonna increase to the point that it becomes viable for a greater number of workloads. And I think that will have the ability, I think, potentially to transform, um, healthcare, um, technology and in a very substantial way. And, um, and I know everyone's talking about cloud and we had to say about cloud, but I, but I can't really, I can't overemphasize the fact that the cost is coming down and it's Google and it's Amazon, it's

You know, it's IBM's even the space now and it's, you know, they've got these third party guys that are trying to compete in this space. They're driving the cost of, of compute and, and performance down. And as that cost comes down, the ability to be able to use that, that, that, uh, platform for more and more of the, of the, of the, of the applications.

And, and I, they're in the clinical portfolio. It will be huge. I mean, we will literally start turning lights out and, and healthcare data centers, um, over the next four or five years. Yeah, we, we, we built a stack and had 14 different layers and we said, okay, if we move to infrastructure as a service, . And we just looked at it, it's like the first six layers go away.

And if we do, uh, software as a service, the first 10 layers go. I mean, and then it just becomes obvious. You're looking at it going, oh my gosh, my, IT organization's gonna be really focused on the consumer, uh, the the internal consumer and the external consumer. Because quite frankly, all this stuff's gonna be handled potentially by.

By external third parties or much smaller team on your side. We're gonna be spending, um, an increasingly large amount of our time as a percentage around integration and interoperability. Um, that'll be, there'll be connecting the devices, connecting the clinicians, connecting to patients, and we'll be a lot more consumer focused than we are today.

And, you know, we will use, we, we have an EBIS function like all organizations do. And again, we're community healthcare organizations that e-business function. You know, I can't develop everything, but we focus on kind of that last mile that provides an additional advantage. We'll do a lot more of that.

We're gonna be start, we're gonna start stitching together, um, a variety of consumer type apps to provide that unified experience for, for, for our patients and our consumers. And that's gonna be where we're gonna focus from a tech stack standpoint. It's gonna be in the orchestration and management of that layer, because I'm not gonna spend time anymore figuring out, you know, how many, how many, um, How many bumps I'm doing, right.

The other, the other amazing thing to me has been to just chat with people. I'm not gonna ask you to reveal yours, but I, I ask people, you know, what's holding you back? And, and invariably people will say different things, but it all comes down to legacy. So much of our environment is still legacy. A significant portion of our staff are still working on legacy, maintaining legacy, and those legacy environments are not, uh, Are not highly interoperable or not, uh, architected in a way that are easy to, to fail over and build a dr and those kind of things.

So you have to, you have to be really creative around it. And some of those environments last for, you know, in healthcare Sure. For decades. It's amazing. So, so I, I honestly, um, I, I don't believe that that what's holding us, what's holding us back, um, is a technical problem. Yeah. Um, I think what's, what's holding us back is, is good organizational operational alignment.

You know, being partners with the business, being partners with operations so that, you know, this is not an us versus them conversation. This is a we conversation, this is how we take this into the next level. How we manage the organization is all about getting this thing, getting this done. And I look at what's different about this organization versus other organizations I've, I've worked with over the years.

That operational alignment is extremely tight. And so that when we just, when we look at it and say, Hey, we think there's opportunity for us to, you know, take some costs outta this or provide additional flexibility or provide additional um, capability. You know, the operational team, we sit down and have that conversation and engage and.

Sometimes it's n now we can't really do this. Or maybe it's, it's not right now, but we put it on a roadmap and we, we work it. So, you know, I'm here later today at, at here, at Chime to talk about, to talk about what we've done around application rationalization and legacy data retirement. And, you know, one of the reasons we've been so successful with this and the team's been $19 million over three years, wildly successful at taking costs out of it.

In the last three years, it's been because we have a tight operational alignment, we've run this as, um, . Run this as a program and we've operationalized it to everything that we do. So we bring something in. This is part of the plan in terms of how we take that out of the system. And a lot of these systems aren't going away to different systems in our data center.

A lot of these things are going away to different systems in the cloud, and I'm managing it differently. That's awesome. Well, thanks for your time. I really appreciate it. Look forward to your session this afternoon. Thanks a lot. I appreciate it. So Tom Stafford, c i o, Halifax Health, Daytona Beach, Florida.

Life's hard, but you had to go from Daytona Beach, Florida to San Diego for the Chime conference. It's very difficult. Yeah. Somebody, but somebody had to do it and I appreciate you, uh, sacrificing yourself to go ahead and do that. Um, you are actually speaking in. Like 20 minutes. 20 minutes. Yeah. So you must be pretty confident in your talk to Yeah, it's a good story.

So it's easy to tell. What, what's your, what's your talk? It's, uh, transforming it, um, and our journey took clinical efficiency. Okay. And so essentially like seven years ago, my IT department hated itself. Our attrition rate was 30%. And then in the last we did a bunch of initiatives. So in the last four years, uh, my attrition rate's now less than 5%.

And uh, we've been named the best place to work in it by computer world for the last four years in a row, like number 10, 2, 5, and five is our ranking. And, uh, now we do some great stuff because I got a stable workforce. I got stable infrastructure and stable systems, which allows us to innovate. And so that's really what I'm talking about.

That's awesome. We could probably talk about that for 10 minutes, but we'll, we'll, we'll go down the technology questions since, uh, You're, you're one of the bold people who actually chose the technology. Uh oh really? Section almost everybody took, took the culture one, because that's a hard one. I think a lot of CIOs are really focused on, on culture, although so are you, I mean, oh, usually that's what you just just described.

That's why I get to come to these things. 'cause my teams run amazingly. Yeah. And so even 'em gone, they're still doing great job. So, so from a technology, uh, standpoint, four questions. First one, um, . What technology do you think will have the greatest impact on healthcare over the next three years? Um, APIs.

Hands down. Yeah. Application programmer interfaces. Yeah. So, um, you know, one of the things, healthcare, it came up in silos. And so I got an HR system, I got a patient logistics system. I have my healthcare information system and they all have good data in them, but nothing talks to each other. And the only way we could talk was through HL seven, which is kind of clunky and unreliable.

Well, it's unreliable, but it's very expensive to set up your interfaces and things like that. And so now that APIs came on the market, it changes everything. So are we gonna see the APIs from the vendors? Are we gonna see the APIs? . From fire and open standards or where? Well, today, I, we, I see the APIs from vendors and so like most of our, even on Meditech too has an a p i and so we use those APIs just to connect things together.

And so back to that golden data, the APIs, let me take the data out, the different systems and then we'll put it in some like next gen uh, clinical decision support system. And provide actual information to our caregivers. And I, I'm a heavy Vocera user and so we're fortunate 'cause I can actually send the alerts predictive or uh, prescriptive alerts straight to the badge.

And it's very specific. So it's the only one that gets alerts that the nurse and the c n a for that patient. That's pretty cool. And so that's kind of, and the APIs is what allowed us to do that. I think people think, so we had 16 hospitals running on Meditech, and I think people think Meditech is a pretty closed system and I, I wouldn't call it the most open system.

Yeah, they're all kind of closed. But, but yeah, you can, you can get the data out and you can, uh, access, access a bunch of it through APIs and. And they're a fair amount of stuff. And even Meditech's becoming more open to letting data in. I was out to dinner with Hoda last night and we were talking about it, so it'll actually help us in the future too.

I love that. . What's that? You say Hoda? It's sort of like saying Judy. Yeah. Yeah. That's one of the, one of the on the meditechs world everyone knows that you're talking about. So, uh, second question. So, uh, our interaction with computers has changed over the last decade from, from laptops to mobile and, and now we're seeing some voice technology.

Mm-hmm. start to show up. Mm-hmm. , um, . Uh, let's talk a little bit about voice here. So, um, where do you think health systems should be looking to expand their use of voice? Voice as in like speech rec? Yeah, or just communications in general? Well, uh, interaction with interaction with technology through voice.

Okay. Just, I mean, we, we could talk about . We could talk about patients using it, we could talk about, uh, clinicians using it, whatever. Yeah. So it's one of my goals as a C I O is to keep clinicians away from computers, which is kind of odd. No, but you have to enter the data. But after that, I should be able to give them the actual information without having them go back to the computer.

Right? 'cause if you think about it, if you're on a med-surg floor, a nurse or a physician maybe goes to the computer every 45 minutes to an hour. and then intensive units are like 10 to 15 minutes, and Ed is like three to five. So if I send something to the computer, it's not timely. And so when it comes to voice, like I said, through vra, it's really easier for us to send out, you know, actionable alerts directly to the caregivers.

And the other thing I'm starting to do with vra, . Is through a voice command, I can change a state of another software system. Oh, right. Yeah. So, and what my current use case is right now for that is, uh, when we go to discharge patients from a hospital, right, so you're the nurse or the transporter? The auxiliary goes into the room to get the patient and essentially they walk out, they take the patient to whenever exit points, and when they come back up to the floor, then they dirty the bed.

So that time when that bed's empty before it's dirty, it's called dead bedtime. And so what I'm working with Serra and TeleTracking right now, so the future workflow would be when the nurse auxiliary walks into the room, they click their badge and they say they want to talk to TeleTracking, and they say Dirty bed 1506.

And so they're dirty in the bed as they walk in the room. So by the time they walk out with the patient, E V Ss is there waiting to clean the room. So if you, you say like you have 30 minutes of dead bedtime. Okay, that time 22,000 discharges is over a, a patient year and a half, which is material. So we're doing that sort of thing.

And then the other thing too is, uh, just voice in general. We're working with Nuance and even Meditech's doing this really cool thing now where you can like . Um, use speech rec to kind of set up notes for you and you can kind of talk in your own terms and then when you go back into the computer, it'll remind you that we need to put this order in for this and that.

So that's kind of where we're heading down the voice path. Yeah. So what, uh, I just had a great conversation on the cloud with a gentleman. So what, what, what percentage of your infrastructure do you think is on the cloud now and, you know, what's the biggest challenges to. Growing that or utilizing the cloud more or is that even a goal?

It's really not a goal for me. Yeah. A lot of my peers make fun of me 'cause I'm kind of cloud adverse. Um, I have Athena, which is cloud-based, and then we also have some third party claims folks. A lot of the rev cycles already in the cloud. Yeah. But that's really about it. Um, my challenge, challenges with the cloud is I don't see the total cost of ownership.

Today. 'cause I'm never gonna go full cloud. Yeah. It So it depends on the scale of the organization, whether you're going to be able to make the numbers work. Yeah. So, you know, we, we had, uh, 40,000 square foot of, of, uh, data center space. We had, you know, tens of thousands of servers. And at, at some point, you see, You get to a certain point and all the numbers start to work.

Yeah. But if it's not there, but, but if it's something be, if it's something below that, and actually it's pretty big, it's still below that, that it's, it's hard to make the cloud numbers work in and of themselves. You almost have to start to layer on, uh, different kinds of, um, use cases and, and, uh, DR costs and some other things.

Mm-hmm. that you normally couldn't do. Yeah. The only thing we're looking at, um, in the cloud right now is to put our final copy. Of the data as the, you know, like our final DR thing, so I'm not holding it in one way. So how are you, how are you keeping up with storage and those kind of things? Um, my organization's pretty kind and I have a surplus of storage.

Oh, you do? Awesome. Yeah, I really do. And so it, it gives me the agility to act like I'm a cloud vendor 'cause I can spool up a server in seconds, like, oh, you absolutely can build out a cloud environment internally. Yeah. And there's enough of the . Um, you can go hyper-convergence, you could do tiered data storage.

Mm-hmm. through a lot of vendors and those kind. And so we, we do a lot of that in house today. And, uh, even in presentation, one of the things I'm talking about is I have a infrastructure refresh schedule that I follow. And so every year I spend the same money on tech and I replace things when they should be replaced.

And so that the kind of, the deal with capital is if you let me spend the money, we don't go down and we've achieved that, which is kind of nice. It's interesting, I, I've been at Major Health Systems where, uh, you do the rounds and you talk to clinicians and they're on like seven year old PCs, and I think I wouldn't even give my kid a seven year old PC to go to, to go to high school.

That hurts H Caps, by the way. Yeah, it's, it does. I mean, they were work. They get frustrated, we're human. That frustration's gonna go into the case. And the simple solution is you put together a schedule and you stick to that schedule. And I do. And uh, I think people think it's more complicated than that and it's not, it was hard the first couple years.

Yeah. 'cause I had to level load the expense. And so like with the PCs, we bought a bunch to kind of catch up, but then now I spend X amount of money every year and I just replace a quarter of our PCs. How do you keep up with the, um, upgrades, . Cycle with, uh, Microsoft and workstations and that kind of stuff.

Um, well, we're moving to Windows 10 now, like everybody, but it's, it's a challenge. And so essentially when, once we see that happening, um, when we buy our PCs, obviously we license them for Windows 10, but we downgraded. Yeah. And then we're, we're actually gonna start rolling out Windows 10 to the whole organization in front of another two months.

We have it in it right now. That's interesting. Everybody's frustrated with the edge. So when you gonna . Roll out Windows 11. No, I'm just, I guess whenever it comes, I No, seriously. Well, that actually when, and now it's, well, Microsoft's becoming very cloud-based too. I mean, OSS is a different story, but Yeah.

It'll, it'll be interesting. But, you know, I, I was talking to somebody I was. Talking to a security person today, and they, and they asked me the question of, uh, I think it was rhetorical, but it's how many, how much windows XP do you think there is still in the environment? That makes sense. And there, there is, especially in biomed.

Yeah. I, I don't think people really recognize this, but some biomed devices are still running on . Xp. I have a few in my en environment. Everyone I can guarantee you, every hospital has XP and it's via biomed. Hands down, you gotta, um, so we bury it, microsegmentation, you know, hide things, but it's fun. Well, I asked you for 10 minutes of your time.

That's actually 10 minutes. The last question was, uh, you know, if we were to visit a clinic, uh, of the future, say in eight years, What do you think that environment might look like in that room? Do you think it's gonna change pretty dramatically? Yeah. I think there's gonna be microphones. Um, with AI coming to where it's going, there's no reason In literally eight years from now, when you walk in the patient room, the physician just talks.

The nurse can talk, um, through voice right now, they can do multiple voices in the same room, so we can pick that up and go ahead and put it in the documentation and the physician reviews everything and hits, submit and done. I think we'll see five G in, or are we, is it too much of a, I, I, I'm, I, I cringe when I say too, I mean, from a security standpoint, we can do all this, it just pops around, but, um, Um, I don't know, but it's interesting when you think about the amount of bandwidth that's gonna be available through the air, and we're gonna have less bandwidth available across the wall.

Like literally the wire's gonna be the choke point, but, uh, that'll come into play too. 'cause when you have that many, um, that many voices that you're trying to compute and it'll, and then having an AI engine decide where to put the information will be. But yeah, it's tough. It's gonna be, you know, hello room.

Yes. Let, let's go and just go do that. I think I, I think that's right too. That's why I keep talking about voice. 'cause I think voice is gonna change everything, but it's gotta catch up. It still doesn't hear everything we're doing and No, it's, but they're getting better. I mean, nuance is definitely doing some good things and it is, and I can't believe some of the words they pick up.

Yeah. Especially on clinical. Yeah. Which I can't even spell those words, but. Well, thank you very much for your time. I really appreciate it. No, well that was a lot of fun. I hope you enjoyed it. That was our second. In a series of three recordings from the Chime Fall Forum, the third one will be released on Friday, and that is with Bill Spooner.

And I'm looking forward to, uh, sharing that with you. And don't forget to check out the YouTube channel at this week in health it.com/video, the website at this week in health it.com, obviously. And, uh, you can follow the show at this week in h i t on Twitter, and you can follow me at the patient cio.

Please come back every Friday for more news information and emerging thought with industry influencers. That's all for now.

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