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July 23, 2021: Our quality measure strategy in the US is NOT working. We need to shift from a process-oriented focus to focusing on eliminating low value care and easing clinical data entry burden. Dale Sanders, Chief Strategy Officer at IMO brings his military, technology strategist and data expertise to the subject. A recent IMO and HIMSS survey reported issues with inconsistent data due to subjective documentation from providers. Despite these issues, organizations are using patient data for quality measurement and reporting (81%), revenue cycle management (60%), and clinical decision support (55%). Is there no silver bullet for improving the quality of data? Will we continue to struggle applying AI until we get a higher quality? There was a lot of confusion around data during the pandemic. What would a much better scenario look like for US healthcare if we see another global pandemic in our lifetime?

Key Points:

  • Why is hiring someone from the military such a good idea for employers? [00:09:59
  • Most patients have an inherent trust in their physician [00:16:40
  • Orders and results have to be harmonized to national standards [00:37:25
  • For the terrible tragedy that was COVID, I think it's going to have a big, positive impact on society [00:46:55
  • The separation between public health and population health that we see in the US does not exist in other countries [00:49:10
  • IMO

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 Thanks for joining us on this week in Health It Influence. My name is Bill Russell, former Healthcare, CIO for 16 hospital system and creator of this week in Health. It I. A channel dedicated to keeping Health IT staff current and engaged. We are joined by Dale Sanders, former CTO at Health Catalyst's new role Chief Strategy Officer for IMO.

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And now onto today's show, we are joined by Dale Sanders, former CTO at Health Catalyst new role, chief Strategy Officer for I. Dale, welcome back to the show. Thanks, bill. It's good to be here. It's always fun to hang out with you. Wow. It's been a while and some things have changed, so I'm, I'm looking forward to, to, to talking about your new role and what you're doing.

What are some of the things that you've been doing? So let, let's start there. You, you've made a, a transition and tell us a little bit about the. Yeah, so I was consulting for IMO for about six months, and then we jointly decided it would probably make more sense for me to be a formal branded part of the company.

And so I went from being consultant to taking this chief strategy officer role, which is kind of interesting because historically I've always associated chief strategy officer roles for we're putting you out to pasture. You're not a very good operator, so we're gonna put you over here in a corner and we're gonna keep paying you, but we are really not gonna listen to you.

So , that was sort of my bias of chief strategy officers, but to Ann Barnes and the rest of the executive team's credit, they wanted me to be more operationally involved. And I said, I, I, I, I'm okay with that, but. I'm a late in life first time father. I've, I've sacrificed a lot of time away from my five-year-old and seven-year-old kids, and I just don't wanna get deeply involved in an operator role right now.

And so if you'll give me the influence without the operational responsibilities. I'll take this, uh, chief strategy officer role and so, so far it's working out pretty well. Yeah, I, I'm having a lot of fun and I don't, I, I don't feel like I'm being put out to pasture . No, it's interesting because I, I, I do some coaching and when we talk with my friends who, and some of my friends who are younger, and I'll say there's seasons of life.

There's a season to be operational and run around and do a lot of stuff. There's a season be strategic. Those things. Those things will change depending on the age of your kids, the experience that you have, the things that you do early on in your career. Yeah. So you just look at 'em as seasons, this, this too shall pass, you know?

Yeah, yeah. And who knows? Maybe I'll get back into an operator role, but. I'm infatuated with our kids with who you might hear running around in the background. You never know. They may come barging into the office with no clothes on. I get Well, . Well, well, we're gonna do this interview back around Memorial Day and so I, I had some questions.

I see you have the flag in the background, but I'm gonna go back there because it was, it was a moving post and on Memorial Day you posted, uh, a picture. Uh, your father and it was our dad and brother served, our mother cried, and it was a tribute to those families that lost loved ones in military service.

Would you mind sharing a, about your dad and brother and, and their service and, and about that post? Yeah, and I might choke up a little bit here, so just be prepared for that. But my dad was, uh, a veteran of World War ii, Korea and Vietnam. Wow. Right. Just imagine that. Just imagine the stress, right? And before that, he came out of the depression and the Dust bowl, and truly just a generation of grit that I can't even imagine.

And he was a true patriot. He was a great father to me and great father. You know, I was the youngest of six, so yeah, he just one of those guys that. That felt duty bound and served in all three wars and finally retired in 1968. He was, he retired from the strategic air command, which is kind of funny because that's, that's where I went back into the Air Force, into the strategic air command.

I kind of followed his footsteps and I'm really glad I did. And then he retired in 68 when, so I was what. Nine years old at the time, and he was a gentleman, farmer and rancher after that. And so it was a great time for me to spend time with him. I grew up roping cows and calves and branding and herding cows and doing all that stuff right and genuine cowboy with him.

And then he passed away from. Not directly from his military service, but he had cardiovascular disease and it was from all the stress and the smoking that went on during all that. So he died at 58 just a few days after I graduated from high school. So, yeah, and my poor mom, I think he had his first heart attack when he was in his forties.

And so my mom, now I can look back on. What that did to her right. Worrying about her husband's health and stress with six kids. And I can appreciate all that hardship now more than, more than ever. But yeah. And then my brother followed my dad's footsteps in the air force too. And, uh, really sad story. He, uh.

Was killed in an accident along with two other people up at Elmendorf Air Force Base. They were, they were turning a sortie around, they were turning an aircraft around for a sortie, and they over pressurized the oxygen system on this plane and it blew up and caused a fire and killed him and a couple of other guys.

And so. That was just devastating to my mom. Of course, she lost, that was the second child that she'd lost was my brother. She lost, uh, we lost a, a daughter before I was born at 18 months, so my poor mom just had, she was, oh my gosh, I just can't even imagine the hardships she went through. Yeah. As a, as a parent, I'm sure it has a, a different meaning.

Looking back now.

For the commitment and the service, but I, I want you to talk a little bit about your service. So you did, you did go the, the military route and that really was a training route for a lot of the stuff you have done since then. So talk a little bit about that. Yeah, I mean, it was just a, an invaluable experience.

I joined the Air Force in 83 after I graduated. Graduated with chemistry, biology philosophy degree at from a liberal arts school in Durango, Colorado, and just randomly, I really had no plans going into the Air Force, even though I had that precedence in the family. But I randomly ran across this recruiter and he rattled off all the different options for me.

I wore glasses, so I couldn't be a pilot and. I was colorblind to, so that was out of question. But he said, we got this new career field that we're starting that's called Information Systems Engineering. And I was like, oh yeah, what's that? And he said, I'm not quite sure either, but I, I think it's where they connect telephones and computers.

And that was literally the conversation I had with him. I thought, huh, well I bet there's gonna be a future in that. And, and literally I said, no, let's try that. I'll apply. So I applied and. The, the application process was actually harder than I expected, and then I was accepted into officers candidate school and then after, uh, that was four months of OCS and then another year of technical training around this information systems engineering program.

Then I thought, well, this was in the Reagan years, right? And the Strategic Defense Initiative was just kicking off and lots of emphasis around nuclear warfare and anti-ballistic missile defense and all that kind of thing. I thought, well, if I wanna be in the thick of information systems, I'm gonna go to the strategic air command.

And, uh, so I did, and it was just phenomenal. It was just a mind blowing experience when you're in your twenties and thirties, the responsibilities they put on you. Yeah, it is. As I'm listening to that story, were you working a lot in cybersecurity at that point, or was cybersecurity sort of out there still?

Not, not, not too much of a concern. Well, it was, I would, it was sort of embedded cybersecurity, like it was sort of a natural part of your job with cybersecurity, but it wasn't the same flavor of cybersecurity that we have today. Right, with an internet connected world. But information security at that time, InfoSec was just a natural part of your upbringing.

Talk about hiring people from the military. I, I would assume you. I mean, they're given such responsibility at such a young age, you can't get that experience anywhere else, right? No. You can't replicate it. You just can't. And frankly, healthcare's always been a little boring because of that. Right. The bar of accountability and responsibility was set.

So high healthcare's always been just a little less satisfying for me. I've always had to find sort of adrenaline elsewhere outside of healthcare with various adventures and things. Yeah. Well, we're, we're going to in your, in your time off, I've been following some of your, your posts and whatnot, and people want us, want us to talk about the, the things of the day.

And I'm just gonna stroll through your, your post because I think some of 'em are pretty interesting. So the first one is I've been advocating that we should shift our US quality measure strategy. From what it is now to a process oriented focus forcing clinicians to enter data in the EHR that proves they are following clinical process, which are proxies for outcomes.

I would argue that we could, we should shift to a quality measure strategy that is focused on the elimination of low value care, measuring what clinicians didn't do, which is the absence of data and does not require data entry. Make sense. There's $300 billion per year wasted in LVC and shifting our focus to that also saves clinical data entry burden.

This is a, this is a passion of yours. You, you've talked about this a fair number of times. What, what was the response to that post? What are you really trying to communicate? What's the core of this? Well, our quality measure strategy in the US isn't working. Even. Even some of the early pioneers who advocated measurement of quality like Don Berwick and Brent James are clearly saying it's not working.

It's not changing the cost quality curve. So for heaven's sakes, if our quality measure strategy's not working, and there's plenty of evidence that all this data entry burden that we put on clinicians to prove that they're practicing according to those quality measures is burning them out. Why don't we pause the train.

Let's pause the train and, and take another look at this. Right? And there's, so there's that body of evidence. Well then there's, there's been this body of evidence around low value care that's been around for at least a decade, probably 15 or 20 years, that if we stop doing just a handful of unnecessary things in healthcare, meds, orders, labs, we save all sorts of money, we reduce patient harm and inconvenience.

And re reduce the clinician data entry burden be, and this is, I think, something that people don't quite grasp. It's the absence of data. It's the absence of an order for preoperative labs. It's the absence of an order for opioids, for back pain that proves that you're, you're not practicing low value care.

So it's actually the absence of data entry. So when I made that post, there were a couple of people said, well, how do you prove something that didn't happen? Right. Well, it, the proof is in the absence of data, whereas our current quality measures is all about documenting, documenting, documenting, proving in some way, justifying in some way that what you're doing is practicing according to the quality measure strategy we have in the country Now.

Low value care is the opposite of that. It's the absence of data, it's the absence of data entry. Where does this reside? Is this a, uh, cms OC? Yeah. No, absolutely. It, it's, this is absolutely within the purview of CMS to do something about it. Oh, it's now the private payers. The private payers play a role too, but CMS as the largest purchaser of government services in the world, or healthcare services in the world.

CMS needs to lead this, and they need to be proactive and aggressive about it, and they got meaningful measures 2.0 that they're working on right now. There was actually quite a bit of momentum around this in the Trump administration, and now I've noticed that there's been a decline in momentum with the transition to the Biden administration on this notion of reducing the burden of EHR data entry on clinicians and kind of rethinking quality measures.

So that's why John Lee and I from Allegheny, Dr. John Lee and I have been on this road show about this topic for, oh, I don't know, a year at least. And we're gonna keep going on the road show and then hopefully I've got a to-do list here to start engaging more with some congressional staff about this topic too.

We'll work it from the top down. That's interesting. I, I don't imagine you'd get much pushback from physicians. I would think they would be cheering you on in this. I have yet, I would say 99 in favor, maybe one opposed. And the occasional voice of opposition comes from clinicians who think that the definition of low value care is gonna be hard for them to follow.

Like sort of the, the conversation thread sort of implies more pre-authorization. There's all sorts of papers published about if you stop doing these handful of things, we save all sorts of money and we prevent all sorts of patient harming inconvenience. Now, I'll tell you one thing though, it's also top line revenue.

Most of these, there's two things that I think stand in the way of adopting low value care. I. It generates top line revenue for healthcare systems when you stop doing these unnecessary meds and procedures. The, the other thing is clinicians will have to face this down and sometimes the best answer to a patient is no, not yes.

And what I mean by that, if I go in and I've got a runny nose and you know, green mucus and I'm asking for an antibiotic. We want an antibiotic, right? That's what we expect as as patients, but it's up to that physician to say no and say, you know what? This is not good for you. It's not good for society.

I'm not gonna prescribe an antibiotic for you. Yeah, that's, that's hard to do because, uh, doesn't that potentially hurt your scores, your customer satisfaction scores, essentially? Yeah. But I think if you engage with most patients in a rational, empathetic way and explain to them why I think most patients will trust their physicians, right.

I think most patients have an inherent trust in their physicians. So you you read a lot. I mean, during the pandemic it was hard to keep up with all the posts that you were putting out there and all the studies that you were reading and commenting on. But this one was interesting, smart health and smart agriculture, and fascinating parallel.

Have you taken up farming and, and what, what parallels are there? Wow, that's a fun project. So I've had a long relationship with Canadian healthcare and in particular in Alberta and the Albert government. Asked me to come in and serve as their senior data strategist, basically exploring the hypothesis that the government should play a role in creating a data infrastructure that benefits multiple industry segments.

So kind of borrowing from telecommunications and highways and railroads and water and sewer and power, right? All those things that the government de-risked for private industry. To build out infrastructure that supports multiple industry segments, right? So the hypothesis is, should we be doing the same thing in the information age around a data infrastructure?

And so the two, the sort of the top two industry segments that we're using to explore that hypothesis are healthcare and um, agriculture and yeah, it's fun, right? So I've got a little bit of a farming ranching background, so I've always enjoyed hanging out with farmers and ranchers and. I've got a biology undergrad, so I can hang out in those conversations about growing things.

And then I'm a data guy, so it's fun. I'm having a blast and I, I hope to finish that report sometime in September. I was talking to somebody about agriculture and they were talking about how, I think it's John Deere. I'm pretty sure it's John Deere has changed their business model to be more of a platform company, a data services company, and they now have so much information on what crops where, how effective, how much, and it's going to be, I mean, they literally, I.

Are, are a phenomenal, uh, one of the largest sources for information on exactly how we're doing from an agriculture standpoint and how much we're producing. Yeah, it's so cool to hang out with all of those. And, uh, I, I wrote that blog with these fascinating parallels between healthcare data, uh, well more like physicians and farmers.

And there's all these very interesting parallels. When I step back to think about it, like one of the parallels was. The, the private farmer. The private physician are both kind of being squeezed out by corporate farming and corporate medicine. Right. But one of the ironic, sort of disco congruent overlaps between the two is that farmers are genuinely interested in the elimination of disease.

I mean, it's profitable for them to eliminate disease for their crops and livestock. It's highly profitable for them to eliminate disease. Whereas in healthcare, we make money off of disease, right? And so it's a little weird. We, we profit from disease in healthcare, we profit from, from health in agriculture, and it's fun to work between those two worlds.

But yeah, going back to your question, I mean, John Deere is just, is one of many, there's a lot of data in smart agriculture and the, the cool thing about it too is there's not . There's not these weird cultural oppositions to sharing data. There's not this in, in healthcare. We've got HIPAA course that sort of transcends data sharing issues and things like that, but I.

There just isn't this cultural momentum against data sharing in agriculture like there is in healthcare. Like Right. Nobody's holding on to data in agriculture in a way. Like I see healthcare systems holding onto their data, not sharing it in, in the US market. You know? I was gonna ask you about your Bitcoin post, which.

First National Coordinator of Health, it, he was interviewed at Chime by Scott McClain from MedStar Health. Oh yeah. And he had a lot of interesting comments and I, I wanna, so here's, and it's in my post today on, on LinkedIn, and he had this to say on, on public health. I came into the government not long after nine 11 when the.

Information sharing from local police department to the intelligence agencies. And I'm right. Yeah. I'm commenting on this because of your comment about sharing and also I, I wanna talk about public health a little bit. And he goes on to say, so it was seamless and integrated and analyzed, and that was a perfect metaphor for the, for public health.

PHXS is what they wanted to build for public health. And we designed that and we could never get it funded. And to this day, we're living with a really dilapidated and obsolete public health information infrastructure. And he talks about during the pandemic, how one of the states had to upgrade their MS DOS in order to get access to something.

And, and I was like, wow. I, I, I can't even imagine. I mean, our health system had some old systems, but that, that would take the cake. No doubt. That's interesting. So I haven't heard that story from him before, but I like those parallels. Yeah. What hap Yeah, that's a really interesting point. After nine 11, we really did open up the interoperability of data between local law enforcement and national intelligence.

Yeah. So how do we do that? I mean, you, you're heavily into data. You've, you've done a lot of this. You've, you've worked with governments and whatnot, so. How do we do this in a way that it's a privacy issue, right? So we wanna protect privacy. There's a general belief that you can re-identify any de-identified data, and so we're worried about that.

There's new paradigms coming up where we're separating the algorithms from the actual data store so that we can, we, we can protect.

Is it just a finance, is the reason this isn't right because of financial? Or is it privacy? I think that we, I think, well the bottom line is I think we overplay the privacy boogeyman and I ran a survey actually when I was at Northwestern and we were, um, just rolling out a portal for patients at that time.

This is 15 years ago, and we were wondering what if it gets hacked and what's gonna happen? I ran a, a survey about patient's concern over their, their healthcare data being hacked and the, and the concern was actually quite low. And if you look at how many times healthcare data has been compromised on a grand scale in us and yet.

Patient's reactions to that is actually quite low, right? Think about all the different payers and healthcare systems that have been hacked and all the healthcare data that's been exposed. The public's reaction to that is actually fairly muted. Yeah. So I think, I think we overplay the privacy, um, risk boogeyman.

And the other thing that, you know, and I'll lean on my NSA days where we were doing quantitative risk analysis in all sorts of different settings, a bad event like. Privacy being compromised depends on three basic things. Motivation of the perpetrator, skills of the perpetrator, and access. Data. Look, every fault tree that I ever created, every event tree that I ever created at NSA came down to those three inputs to the top gate, right?

And, and when you, when you really do a quantitative analysis on access skills, motivation to do something bad with healthcare data. It's actually pretty small now on the Black mark. Medical records are pretty important for identity theft and all that kind of thing. They pay a premium for that kind of thing.

The credit card data is almost meaningless now because the credit card companies have taken care of that. Financial data is actually quite easy now to protect, so I would hope that going forward we start thinking about real versus perceived risk. The perceived risk around privacy is a lot higher than the real risk number one.

And number two, if and when there's a compromise, we can work faster to mi mitigate it just like their credit card companies have. So, national patient id where, where, where do you stand on on that whole conversation? Well, we've gotta have one. It's just. It's again, the boogeyman of big government monitoring and all that, right?

To get a national id. I mean, come on. That is a very vocal minority of people that oppose a national patient identifier. Most patients, most patients, especially if they knew the benefit they would have to them, would say, absolutely, sign me up. Let me have a, a national patient identifier. So, so what is the benefit?

Well, it's, it's the ability to integrate records consistently. Going back to the public health and, and population health sort of, and the care delivery network. I'll give you a great example. If we had a national patient identifier, it might be possible, it would be enabling that where I got my vaccine would actually show up in my medical record in Intermountain Healthcare, right?

So I'm part of Intermountain Healthcare Network here in Utah. My EMR record has no indication of my vaccination. And so, right. And, and so fundamentally, if you don't have a patient identifier that crosses over between where I got my vaccination and Intermountain Healthcare, you can't put Dale Sanders data in, in, in a, in a repository.

Right, right. But there's very little, you're talking about two private, well, one public probably. And. Data system, what's the incentive for them to pull that data together? There isn't one right now, bill, that's the problem. Right. I mean, it's interesting to think about the incentives around law enforcement exchanging records.

There's no financial incentive for them to do that either, but there's a cultural incentive. There's a cultural imperative. And in healthcare there's no, there's still no great economic incentive for systems to share their data. For some reason we haven't reached the cultural tipping point, like law enforcement and anti-terrorism did.

Maybe Covid will push us over the top. I don't know. We'll see. It's interesting because I have not been a fan of national patient id and the the reason is 'cause I think the, the information should aggregate around the consumer. And we aggregate information around the consumer all the time. I request this data, I request this data from each one of the systems that I've been, uh, part of.

And at that point, there's a number of identifiers that already exist around me, right? I mean, you can just look at my address, my phone number, my name, and those kinds of things. And you can say, this is probably this person with a.

And, and six. In Southern California gave us incorrect social security numbers. They probably were not, potentially, not legally in the country and those kind of things, but we still provide them care. And so it was hard to match the record and without data it's hard to match the record period. So, yeah.

Well, and it's hard to do longitudinal health analysis if you don't have the ability to link my data over time. I mean it, all of us should have some sort of longitudinal view and trajectory of our health, and it's very hard to do that as an analytics guy. I can talk all about that, how hard it is to pull data from disparate systems about Dale Sanders.

If you don't have a common identifier, why do you not support a national patient identifier? What do you, is it just conceptually off base you think? Because I, first of all, I think there should be joint custody of the record, right? Mm-Hmm. The record today is owned by the health system, and I think they're, I don't, I don't think they shouldn't own it.

They do, and I understand that they created the record, but I should have joint custody because it adds so much value to my life. Absolutely. And so somebody with joint custody, I'm looking to big tech or somebody else. To come along and, and give me a tool where I can make the requests and gather all the information.

Then I think what's gonna happen is we're gonna have an ecosystem of players that starts to cr get created around that. And it could be Intermountain who comes around and says, look, you've collected all that data, not only from there, but also social determinants data, also data around your groceries, your.

What I want is I want to create that system, that ecosystem, as quickly as possible. And I think it has to be done around the consumer where there's an incentive for people to take all my information, see my whole profile and say, all right, yes, we are gonna help you to live a healthier life. 'cause quite frankly, if I want, if I'm really sick, I'm gonna May, and if I am, if I'm moderately sick.

I'm going down the street and if I don't know what I have, I'm just gonna go telehealth and there's not much differentiation for me. But if somebody's gonna finally come alongside me and say, look, I don't just want your sick care dollars. I wanna make sure that you stay healthy. I wanna make sure that you take off the Covid 15, and I wanna make sure.

You understand that your father had these conditions and it has this impact on you? Yeah. Those kind of things because my dad had heart issues pretty early on in his life, and I'm actually past the age of his first heart attack, so I worry about such things. Mm-Hmm, . But my health system in this has my, has all these records and no one's looking at it today 'cause I'm not there.

Mm-Hmm. . Interesting. Yeah. So I, I wanna find somebody who's gonna actively participate in my health. And I, I don't think that's, I don't see the health systems running in that direction because again, the financial incentives aren't there. Right. So that's why I'd like to see this system created outside of it.

I like it. Interesting thought. I like it. Yep. I wanna talk a little bit about your future here. So you, you went over to IMO. Tell us a little bit. Im strategy. Strategy. That's right. Well, I, I was one of IMOs first customers back at Northwestern, and it was around clinician friendly terms at the front end of the EHR.

At that time, clinician dissatisfaction with EHRs was so high. It was like anything that I can do to make a little more comfortable with Epic and Cerner at that time, I'm happy to spend some money on it. And clinicians preferred using the IMO terminology to manage their problem lists. Three to one over SNOMED and ICD and that kind of thing.

Oh, wow. So, yeah, so, and I ran that AB test and, and so I, for the money, it was clearly something that I wanted to do to add a little bit of life to, uh, or a little bit of satisfaction to the lives of, uh, clinicians with the EHR. The other thing I was doing at the time was building the da, uh, enterprise data warehouse at Northwestern.

So I wanted to carry those terms, those IMO terms that were more clinically precise all the way through to analytics. And the notion being that more clinically precise terms on the front end means more clinically precise analytics on the backend. And we made progress on that. We did a little bit of that in Northwestern, but then, you know, I moved on to the Cayman Islands, kind of left all of that behind.

Went on to Health Catalyst and it's sort of an, an unle, it's an un unsatisfied part of my life. I want to go back to that and deal with data quality and physician experience at the beginning of the data journey. So I've been sort of the analytics guy in healthcare for since 1997, and I've been struggling with data quality.

Analytics ever since cleaning up data? I mean, I mean, the cleanup that you have to go through as an analytics company and an AI company is insane. And the truth is, it's a dog chasing its tail because you never really get ahead of the data quality problems. The, the problem with data quality starts at the beginning of the data stream.

So what I hope I can do at IMO is a couple of things. I, I want to continue to leverage IMOs clinician friendly experience, personality around EHRs. Which means that I plan on and advocating some, some new things that we're gonna do in the, in the EHR experience world with IMOs brand and then. Downstream from that, recognizing that not all data is going to be standardized to national terms, international terms, we'll always have a need for curation of data and normalization of data.

So we're building out tools to speed up and accelerate the accuracy of normalizing disparate EHR and clinical and claims data. We're kind of leapfrogging what's out there in the industry right now with those normalization tools and. Downstream of that, I want to take a run at making value sets more meaningful and useful.

We we're off track as a country, I believe, with the value set authority center. No criticisms of the people. I love the people there, but the strategy of the Value Set Authority Center has never really reached what we had hoped it would be way back in 2008, 2009 when we were, I. Kicking it off. So value sets is another area that we're gonna play a big part in with IMO, again, maintaining that IMO terminology throughout the lifespan of the data.

Also, and I don't know that everybody understands this, but IMO has a proprietary terminology, but it maps to all national and international standards in the backend. So you get the, you get the best of clinically friendly, clinically precise terms with all of the national and international mappings in the background.

So it's, it's basically addressing these data quality problems that have driven me crazy as an analytics guy, I wanna get upstream of it to the clinician experience, to the data quality curation pipeline. Yeah. It's, and it's amazing how much, uh, money and effort goes into that piece. And we want it to go downstream a little bit in doing research for, uh, our conversation.

I came across a study that IMO and HIMSS did. It was a survey of clinical business and IT personnel, various US hospitals, and they were looking to understand how patient data is being used in decision making analytics, and how challenges with data quality are getting in the way of achieving enterprise, uh, goals.

And the, the research was interesting. 57% reported that data is inconsistent.

There's no surprise there. I guess 50% said that the data derived or extracted from external S sources is variable in accuracy and completeness. And despite these issues and others, organizations are using patient data for a range of initiatives, including quality measurement and reporting. 81% revenue cycle management, 60% in.

Percent. This data quality is a, an issue. Every time we, you and I get on the line, we, we end up talking about it. There, there, there is no silver bullet. I mean, you, you are going to be doing some things here and leapfrogging, but there there's no silver bullet that, that at the front end, the clinician's just gonna go, this is a perfect note.

This is the perfect documentation. This is the perfect order. Yeah. Well that's true Bill. What I would say though, as a country, I. We, we need to mandate that orders and results as a minimum orders and results have to be harmonized to national standards. At at Catalyst, we built Touchstone, which was this national repository of EHR data, and depending on how you slice the data, at most 20% of lab results.

Are harmonized to loin. So, so 80% of our lab results have no associated loin code with them. And for medications, it's even lower. It's less than 1% harmonized to RX norm. And the analogy that I use for that is imagine if you went to the grocery store or to Target, or to Walmart or whatever else, and one out of 10, maybe one out of 50 products had AUPC code on it.

What would be the implications to the consumer experience? What would be the implications to the supply chain to the manufacturer if retail products didn't have UPC codes on 'em? So UPC codes are to retail, what standard terms are in healthcare, and we have not embraced it, and it's ridiculous that we don't.

It should be a mandated law. Every lab order, every lab result, every medication order, every medication prescription should be associated with national and international standards, and that's something that has zero impact on the clinician experience. By the way, that all happens in the background when you set up your Orderable catalog.

And the only reason that we're, that we're harmonizing to anything right now is if it's associated with reimbursement. That's why the numbers are so low. Yeah. So if you're sitting in the CIO chair, I just hired you to be my CIO for the health system, what, what are you doing to get ahead of this? I mean, are there some, some, there's some basic blocking and tackling that are is pretty, pretty easy to, to get done.

Well, fundamentally, when you deploy your EHR, we should have all built. Orderable catalogs that were harmonized to national standards, right? Very few, if any organizations did that. Now we've gotta go back and retrofit 'em. So I would kick off an initiative and say, look, we're gonna lead the way with this and we're gonna chip away so that every one of our orderable has a national standard term associated with it.

Even if it doesn't have anything to do with reimbursement, everything we order is gonna have AUPC code associated with it. And by the way, I'll comment on this too, bill, the, going back to the military for a second, I was weaned from military commanders who insisted on data quality. Right. It wasn't a nice to have.

It was like, goddammit, Lieutenant, make sure this data is accurate. Don't come back until it is. And by the way, if we need to build more satellites and sensors to make this data better, then let's go kick off for procurement to do that. So there's, there's an insistence at the leadership level of the military around data and data quality and data analysis that does not exist on our healthcare executive culture Now.

It's that kind of insistence around being informed for decision making that's missing in the leadership of healthcare right now. And I don't think healthcare executives ever really get exposed to how poor the data quality is that they think they are, that they think is high quality, and the decisions that they make are so off base.

They ask for reports, we give 'em reports and we've cleaned it all up and we put it in front of 'em. They go, oh, they can tell us within, but we know from. Well, I mean, this is sort of an interesting one, but, but we know from IBM Watson that the quality of the data was unable, was not good enough to train AI models, and we're seeing that over and over again.

That same challenge. There's a great paper, by the way, on data quality that Google wrote in March. I highly recommend to everyone. I've, I've got it out. I've published it on social media a couple of times. It's called Everybody Wants to Do the Models. Nobody wants to do data quality. And, and so here you have Google, arguably the most sophisticated AI culture in the world.

Who could easily overhype AI saying AI is underperforming across a number of sectors, especially healthcare because the data quality is so poor. Everybody wants to be a data scientist. Nobody wants to be a data normalization and data engineer on the front end, not not looking at . Mayo or HCA, but looking at the agreement that Ascension did with Google, think about the the data, I mean just the data aspect of this.

So essentially what Ascension said is, look, we're not gonna do the big EHR implementation to get to a single standard. 'cause they have a hundred hospitals and literally like 70 or 80 Right. EHRs out there, or whatever the number is. Yeah. And so they said, all right, here's what we're gonna do. We're gonna find.

The premier data company in the world and we're gonna partner with 'em. So they partner with Google. All the data goes there. They create a clinical interface of some kind that integrates into the EHR, no matter what it is, where they can do, uh, have a different interface to, to pull together all the longitudinal record into search it just like you would search Google and, and a bunch of other things like that.

I've seen the video on it. It's really fascinating and it's, it's, it's really kind of compelling when you see it. But that's really hard to do, isn't it? I mean, they had to essentially the, the microcosm of what we were just describing, they had to do across 80 or a hundred hospitals and saw that data and had to figure out how are we gonna bring all this stuff together?

Well. The truth is it's not as hard as everybody thinks it is. And, and we basically did that at Health Catalyst. So wherever there's a data operating system from Health Catalyst installed, that disparate EHR data has been peeled out of those EHRs and, and put into the data operating system. And then over the top of that is a care management skin, a web app, a mobile app that looks at that data from a patient across the continuum.

So re. Healthcare data is not that hard, really, bill? So I, I, I do think the app that Google put together was cool, but the truth is Health Catalyst did it quite a while ago, and it's not that hard to do once you peel the data out of those systems, put it in a nice, modern infrastructure. The software tools we have now today, I mean, it makes it super easy to re-skin that data and, and make it a lot more user-friendly.

You just have to keep the, the source data. To reference, I would assume? Yeah. At any, at any given time. And you're using tons of metadata, I would imagine, around the data. It depends on how you define metadata. Well, I mean, if, if you're gonna be , whenever I hear re-skinning and, and all those kinds of things, I remember the conversations I was having with physicians.

How do I know where this, this data originated from? How do I know? Just all the information around the data itself that they wanna know. Is patient generated? Is it physician generated? And, and so anytime you re-skin it, they're gonna go, alright. What? Where'd it come from? What was the context? Yeah. Well I can't claim that we did that and I, and I don't know, I don't recall seeing that in the Google app.

Yeah, that's a good point. It's a good point. Yeah, and I'm not, I'm not sure it's there either. I was just sort of, it, it's, it's just interesting to me that that whole thing. Let's, let's talk a little bit about the, the pandemic we're not through yet. I think we're approaching 70% people vaccinated.

Something to that, I don't know what the exact number is. I know there was a target of 75 by the 4th of July, and I don't think, kind of look at it's fingers.

That 14, 15 months after we identified something that we have 70% of the people vaccinated in the United States. We, we, we have a vaccine, we have multiple vaccines. I, I, I, I think sometimes we, we don't recognize how amazing it is where we're at 'cause we're too busy trying to politicize the, the whole thing.

Yeah. But it's pretty amazing, isn't it? Oh, it's mind blowing. Right. And it's very interesting for me, the juxtaposition. Between how amazing the vaccination process went versus the situational awareness of what's going on with Covid. Who's got it? Where are the outbreaks happening? How many patients do we need?

What's our ability to manage this from the capacity capability, right? We were off the charts, terrible at situational awareness. And you think about all the thousands of beds that, that we put in exhibit halls in anticipation of overwhelming numbers. We just had no clue about the situational awareness and the rate of infection and all that kind of thing with covid terrible at that stuff.

Right. The vaccinations like is mind blowing. I mean, it's, it is truly admirable and, and I. It speaks to the power of the country, and I think we all should be kind of humbled at the scientists and the engineers and the logistics that went into the vaccination. It's fascinating, and I just saw the other day, now we've got CRISPR and Messenger, RNA technology kind of coming together with the first vaccination of its type.

To treat a genetic disorder. So yeah, COVID for all of its terrible tragedy is kind of in, I think it's gonna have a big positive impact on society. Yeah, it's, it's, I, I remember I was talking to a guy early on in the pandemic and I was talking to him about a vaccine and he goes, you shouldn't expect a vaccine for another two years.

He goes, and that's, that's quick. He goes, typically, what we're talking about is three to four years for this, for something you're gonna roll out in this level. I'm like, it's amazing. I'm like, are you kidding me? Dr. Klasko did this, his thing pandemic 2030 and he, he, as he's prone to do, he creates a slide deck of, Hey, here's how we're gonna experience it in 2030, and.

He sort of, he paints pictures and I like that from leaders. I like when they paint pictures that we can follow. But you, you pointed out, and I remember following your, your post early on in the year, um, there was a lot of confusion. Can we get covid from cardboard boxes from Amazon that we're receiving?

Can we, how does it spread? And those kind things. There's a lot confusion. What would you like to see? What do you think needs to be in before 20?

Let's assume it is, what would you like to see in place, uh, from, from your world perspective, from your data perspective? Yeah, so good question, Fran. I, I've come into this advocacy for a data strategist and it's, it's a new sort of skill I think that we all need to recognize. I didn't really appreciate the value of it until I was participating in some of these covid.

National forums where people were just not thinking about data strategy at the level that I thought we should. So if you would step back and say, as a data strategist, what do we need to do? What have we learned about from Covid that we need to apply going forward? There are a couple of things right off the top of my head, and that is this distinction we make between public health and population health, infectious disease and chronic disease.

We gotta stop that, right? So not only is it a cultural barrier that should not exist, and by the way, in other foreign countries does not exist. The separation between public health and population health that we see in the US does not exist in other countries. So culturally, those two worlds have to work better together than they do right now.

And then stepping back, we have to say, what's the data strategy to tie those two worlds together? Right? Because if you think about Covid, for example, COVID is an infectious disease. That's the world of public health. But go tell those nurses and doctors in the healthcare facilities. That's a public health issue that was absolutely a population health issue that overwhelmed our clinicians, right?

So this distinction that we make between public and population health has to stop. And then beneath that is the data strategy that ties those two worlds together so that we're sharing data between the two and coming back to standard sort of classic decision theory, which comes down to situational awareness.

I. Hypothesis generation about the situation and then interventions and assessment, right? Once you generate a hypothesis, you intervene, you do something, you step back and you look at it. That's classic decision theory, right? So taking a data strategist approach that brings those two worlds together and a decision theory approach to the data that we need to support those three components of decision making.

Is I think, fundamentally important to the future. Dale, I want to, I wanna thank you. I, I always like sitting down with you and I, I look forward to sitting down with you more. In, in your chief strategy role, are you going to be at any of the upcoming events that are on the calendar, HIMSS Health, any of those conferences?

Yeah. I, I'm owed marketing team tells me I have to go to hims. So , so I'm going to hims and I'm doing a little bit of traveling, but you know, I'm never gonna go back to traveling like I was at, at Health Catalyst. I, there's just no need for it. And again, falling back to my priority in life right now as those kids and I'm, I'm never going back to traveling like I did.

No, and I, I understand that completely. I'm sort of struggling to go back to traveling at all, to be honest with you, because Yeah, right. This is, this is pretty nice, uh, to have dinner with the family every night and see everybody and still get to interact with your peers and have conversations. Uh, there's, yeah, totally.

I mean, I, I think I've had more one-on-one personal conversations in the last year and a half than I ever have in my life. Thanks to Zoom and Teams and everything else for that there. There is a lot of waste in travel, isn't there? Oh, totally. Well, Dale, great catching up with you. Thanks. Thanks again for your time.

Appreciate it. Yeah, sure Bill. Thank you. Keep doing good work. Appreciate you. What a great discussion. If you know of someone that might benefit from our channel, from these kinds of discussions, please forward them a note. Perhaps your team, your staff. I know if I were ACIO today, I would have every one of my team members listening to this show.

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