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 Welcome to this Week in Health It where we discuss news, information and emerging thought with leaders from across the healthcare industry. My name is Bill Russell, recovering Healthcare, c I o, and creator of this week in Health. It a set of podcasts and videos dedicated to developing the next generation of health.

Today a little back on industry health IT priorities. This podcast is brought to you by Health Lyrics. Wanna start your Health IT project on the right track or wanna turn around a project? Let's talk Visit Health lyrics to schedule your free consultation. Our guest today is a retired healthcare c i and physician and a good friend of the show, Dr.

David Ben.

Bill thank having me. You know, we usually start with a softball question of, you know, working on and

yesterday woodworking on, uh, do mind talking about a little bit. Yeah. One of the great things about not having a strict schedule, I'm, uh, able to do some, uh, more woodworking, but I have four grandsons and so they dictate a large portion of what I do. My five and a half year old has been obsessed with the Titanic for the last two and a half years.

In fact, he was John Smith for Halloween last year, captain John Smith. Wow. And so he asked me to make a wooden replica of the Titanic. Um, he had seen the replica of the Disney Magic that I'd made for his cousin. And so now he wants this. So I'm hollowing out a large walnut timber to make the hull, and we'll start building the lower decks, uh, later this week.

So the two obvious questions are how does a, a five-year-old become obsessed with a Titanic? I, I guess that's the first, first question. So what, what, how does that happen? Yeah. So he, he saw a book, um, in the store, uh, that had Titanic on the cover. He decided he liked the look of the ship and he started having his mom read him things about the Titanic.

There are things you leave out when a child is three and a half to five and a half, and so there's not a lot of discussion about the loss of life, right? But there's a lot of discussion about how it was the most modern ship of its era. So he has done a, uh, little Lego type block, um, replica of the Titanic.

He has built cardboard replicas. Um, my basement is strewn with cardboard, uh, from his efforts and just stays with it. And yeah, it's, he is an interesting little guy. He's, he's my, uh, mechanical genius kid. Wow, that's amazing. I, uh, you, I guess the, the following question is, uh, do you have to be a grandkid to place an order for one of these ships?

I would imagine the answer is yes. Well, if, if you're not one of the grandkids, you get way to the back of the line. , I imagine the line is, so how, how are you keeping up on what's going on in healthcare? I mean, is there, is.

Yeah, I'm, I'm still very actively involved with the, uh, state Medical Association and with the American Medical Association. I'm a delegate to the American Medical Association and one of the areas they look to me for is my experience in health it, so that causes me to wanna keep reading. And, um, one of the other great ironies is I have more time to read now than I have in my entire career.

So I probably read two to uh, two. In the industry and then do some pleasure reading. Uh, right now I'm reading a book Loathing Lincoln that was written by one of my old track teammates, and it's about the, um, way over the years that people have chosen to manipulate the leg Lincoln legacy, uh, whether, um, conservative or liberal, et cetera.

Um, it's always been an interesting thing how we twist things, but I have a lot of time to read. I'm enjoying it. Yeah, I, I would imagine that would be an interesting, uh, interesting dive. So it's, it, it's been, it's been a while since I've had you on the show, and I wanted to catch up with you on, uh, the priorities and emphasis that we're seeing in the first half of 2019 from healthcare.

And, uh, you know, two of the things that we've sort of talked about ahead of the show to Social of Health, the. And, uh, I'm gonna let you kick it off, so I'm gonna let you kick it off with, uh, let's start with social determinants, because that was a huge topic at JP Morgan. It was a huge, uh, emphasis at, uh, thes conference.

And I think a lot of health it people are saying, okay, you know, I mean, you've been collecting these, these.

You know, what else do we need to do? I mean, where, what's, what's the, all of a sudden the, the mass emphasis and how are we gonna get our arms around it and make it pal, uh, make it digestible, I guess. Yeah. So it, one of my concerns is it has been around for years. W uh, W H O, the World Health Organization has talked about social determinants for many, many years.

And we know on a macro level that if you look at populations and you determine, um, How they fit into these 11 domains of social determinants of health. You can show evidence that people do better when they're in certain categories and worse when they're in certain categories. But now we're asking primary care physicians or point of care clinicians to capture these 11 domains in a more formalized way because we wanna be able to do the data dives.

We're burying the people who are already buried. Um, so my concern is it's a great catchphrase. Everyone talks about it. Um, it's kind of like population health, um, has been, we love to talk about it. There's a whole bunch of people making money talking about it, but no one's really solving it. I think the American, um, academy of Family Practice has probably done the best job in determining.

How do we get it into the workflow and creating, um, a conceptual framework for how we bring it into the workflow. But my personal opinion is that the data gathering is going to have to be through a patient facing interface, uh, uh, uh, registration process, much like they do for their pre-visit, um, registration in, uh, MyChart or other, uh, patient.

Uh, portals and then we have a chance of using background diagnostics, background analytics to present opportunities to the care team at the point of care. But if we expect it to be done by the care team and created by the care team, it's not gonna happen. We're basically asking people to do what the Census Bureau cannot even do.

We do a sampling as a census bureau, and now we're turning to the care team and we're saying do a hundred percent do every single patient who comes in, every single American, every single uh, person seeking care in these areas that are really Census Bureau type. Data. Right? Um, how do we make that work better?

The A A F P, I think is on the right track, but we don't even have research that shows that on a microcosm level we can impact. Social determinants. We know, we know it on a macro. We don't on a micro. Alright, so I put back in the chair, you're be the for, for a system that's, uh, now you, you were in a, you in Kentucky.

So let, let's, let's take you to Chicago. I mean, 'cause social determinants in Chicago would be a, a, well, I'm sure it's in Kentucky as well, but let's take you to Chicago, um, because, you know, there are, there are, uh, let's see, there, there are documented cases where, you know, zip code really matters and you could literally live across the street and have completely different outcomes.

So, Sort of escalated in its, um, in its importance are yes, right now, plus the push for population health. Um, so I make you a C I O and I say, alright, the physician community's looking at us saying too much data. I, I mean, you're already asking me to see a patient in 15 minutes. In those 15 minutes that I, I don't have enough time to go through all this data and, uh, have a meaningful, uh, dialogue with the patient about, uh, what in 15 minutes in some in Chicago might be kind.

I mean, it might be eight minutes or something to that effect. Um, so, uh, they're gonna look to you. They're gonna look to you, the c i o and say, um, you know, take all this data and we're now connected. We're getting housing data, we're getting education data, we're getting all this data. I want you to make meaning of it.

Where do you start? Yeah, so I, I think the first place you start is with much better analytics than we currently have been applying and analytics that's in the background, and then presents prioritizations and succinct opportunities to the clinician and not more than three at a time. Um, and it's kind of like what I've talked about with, um, uh, the alerts.

I don't want a ton of alerts, keep it to a limited list. I'll work through 'em. If once I've addressed something, it goes into the system and it knows not to bring that alert to me. Again, same with these opportunities and social determinants. My team and I as a primary care physician can work on the two to three, and once we get them off the list, new ones come up.

Um, so better analytics in the background a. Seamless presentation to the physicians in the workflow. And then the, the big thing is it cannot be on the primary care physician or the specialist to implement a lot of the interventions. A lot of 'em are social interventions, public health interventions, societal obligations, so, We can, as physicians, make the patients aware that they have these opportunities and point them in the direction.

But our nation, our system has to do a better job of providing those resources and making sure they're responsive to the needs of the patient. So it it, but it starts with the analytics. Um, and it, again, as I said earlier, it starts with the capture of the information, which is gonna have to be largely from the patients, recognizing that we have a percentage of the population that is not literate and is going to need assistance, but the vast majority of us can enter the basic information about ourselves.

Address type informations. It's interesting. Do you think we'll see a lot of over? Well, I mean, because I, one of the areas this really gets highlighted in, in a, um, in a, uh, in an urban setting is in the er. Um, because you have a lot of people present, uh, in the er who, uh, quite frankly,

Those core social determinants and, and one of the things our physicians were asking for was it, it's too hard to find all this data within the e r. Now we can argue which e h R is better at that or whatnot, but none of 'em are great at it. And so what they were asking for was an overlay. They were asking for something where they could get a quick snapshot.

And obviously behind that is a whole bunch of integration so that you can pull that data outta the e H r a whole bunch of, uh, analytics, be it predictive or, uh, retrospective analytics, uh, be it machine learning or ai, the buzzwords on top of it. And then you're presenting that in almost like a, a red, red, green, yellow kind of thing.

So they can look at it and say, uh, you know, there's a housing issue and it almost has to be single click. Like, okay, I'm gonna make a, um, just like you're prescribing medicine, you're like, I'm prescribing housing urban development to help you.

Simple. It can't be the doctor sitting down and saying, Hey, let's talk about your housing situation. Oh, you don't have air conditioning. I, that's, that's not really gonna be their role. Probably, I wouldn't think. Right. Um, but I think you're right. It needs to be presented in a, again, in the workflow, much as we do with opportunities for immunization, opportunities for screening exams.

In the system that I was with Baptist Health, they're now using the E H R to present to the physician at the time they open the patient's, um, chart those opportunities and it's presented to their medical assistant. And there's opportunities where those can be ordered by the medical assistant to be confirmed by the physician.

We're trying to simplify doing the right thing, and we've seen our screening rates go up since the implementation of the integrated D H R and providing that. We need to do the same with social determinants. Not expecting the physician himself or herself necessarily to address those, but their awareness and their pointing the team to say, what can we do or where should we refer?

That can be done by the whole care team at, can be done at the discharge test, by clicking on a couple of those social determinants. It then tells the discharge person, Make sure they have an appointment with social worker. Make sure they have, um, the address and a contact at the food bank. Make sure they have, you know, whatever, um, a contact at the gas company so that they don't get their desk shut off, they have heat.

Those things can be done in the workflow. We just have to present them better in, um, the dashboards and make it be as simple as one click. Anything more complicated, it's not gonna happen. I did care for 16 years and I was overwhelmed in 2006 up. Can't imagine being.

So yes, we're gonna, we have to make meaning of the data, there's gonna be more data than ever. That's the role of the c I o, chief Information Officer to do something with that. So, uh, you referenced, um, a framework that has the 11, uh, categories. Uh, which, what's the reference for that? Um, the reference is the perspectives in primary care.

It's a 2016 study by the, um, or editorial by the American Academy of Family Practice. It's in their journal. Um, and, uh, lemme see if I can quickly give you the actual date. Um,

it's Annals of Family Medicine 2016. Um, colon 14, um, colon 1 0 4 through 1 0 8. Okay. So, so it's volume 14 of the American, um, family medicine, um, journal. So social determinants of health. Uh, uh, here's the thing I like about this conversation is we were, we were talking about interoperability almost the same way we're talking about this now.

Uh, maybe five or six years ago. It was a huge hype at himss. Uh, chime. We were talking about interoperability. If you went there this year, interoperability. Was a, was a huge focus, but it was more showcasing just a ton of solutions around interoperability. And we've, um, we haven't tackled this problem to the ground, but there's been so much momentum on it that you're starting to see solutions rather than, um, people sort of throwing their hands up saying, well, you can't do interoperability in healthcare.

And I think the same thing's gonna be true here. You know, you have this escalation phase. Everyone's talking about, about, and, uh, and the community's gonna go about solving, uh, this problem. And I think in two to three years, uh, you know, we'll have a new problem to solve, but social determinants will be something that we've, uh, hopefully wrestled to the ground in, in a few years.

Um, that's, that's my hope. Yeah. I, I think from a knowledge base and any presentation base, I think you're gonna be right. I think from the real solutions. That's a huge social lift that's well beyond you and I and the it world. Well, and, and it's nonmedical, right? So there it's way beyond healthcare as well.

I mean, there's, there's so many, uh, institutions and agencies we gotta figure out, um, data sharing across that. We gotta figure out referrals across that. Uh, so we're creating sorts.

You brought this one up. I, I'd love, I'd love for you to tee this one up. Yeah. So consumer-centric care is another one of the catch phrases of the last year and a half. Um, and when I hear it as a primary care physician, c i o, I hear it thinking it cannot be consumer because patients come different than a consumer.

If I walk into my local appliance store or my local, um, auto dealership, I'm then, I'm truly a consumer. I'm able to be informed about the. Come in with my money. I know how the interchange is going to happen. I pretty much control a large portion of that interaction. And the most important thing, I don't need either of those.

I may want those things, but I don't need them. So I can walk as a patient, I need care, and I come fearful and I don't really understand the pricing. And even with, um, posting, uh, the charge masters. I still have no clue what the pricing is for hospital, uh, care and no immediate ability to fully understand that.

No one's going to immediately understand all the abbreviations, the codes, uh, uh, even if you put it out as DRGs, you know, it's, it's just hard for the cons, the patient to really understand it, and particularly in a moment of stress. So I kind of rebel against the consumer centric. I think we need to think more, how do we care for people holistically?

In a way that does work to delight them. I mean the, the consumer catchphrase of a couple of years ago was delight. You know, anything I present to people should delight them. Well, I always thought that way about my practice. I always wanted a patient leaving, anxious to tell five more friends, you need to go see Dr.

Sma. And if you approach it with that attitude, then you are always going to be. Focused on the patient. Now, that doesn't mean you give them everything they want. It means you explain your rationale and you engage them and then, um, partner with them in that care. But to call it consumer-centric, i, I just think is a misnomer.

Yeah, it, it's interesting you brought that up. Um, and I haven't really thought about it in a while, but when we were, uh, developing our models around this, I would say about six or seven years ago, um, as c i o, we, uh, we always kept consumer and patients separate. And the reason we kept upset, we had one, there was one 5 million in.

We just call them consumers. They didn't have a medical record. We didn't see them, and we said, but we still have to care for them. What category do we put them in? Well, they're a consumer of health, but they're not a patient, so let's just call them consumers. But we had a clear delineation that once they came through the door, they became a patient.

So there was, there was, there's different, um, there's different strategies. There was different technologies. There was different approaches to how you care for somebody who's not a patient versus how you care for somebody when they become a patient and a whole, not a whole new set of tools, but a lot of the tools are very different.

Um, you know, you go from, Hey, we're measuring stuff on an Apple watch over here to, hey, we're actually gonna connect them to an EKG or, or e CG over here. I mean, the tools are different. The, uh, the technology's different how you're, you're measuring it over here in the consumer world in a database that's outside the m r, but once they step through the door now,

Um, but I, I can understand, I understand where you're coming from in that if that's not

in. Uh, maybe from the perspective of they have a choice and you wanna, you want them to be happy, that's great. But doctors have to say some hard things, right? I mean, people aren't always gonna walk out happy. Um, yeah. And so we, we used to talk to our system about the fact that the consumer centric was the marketing aspect.

It's how do you get a community presence? How do you make awareness in the community and trust in the community? How do you develop that? Whether it's through Facebook tweets, uh, newsprints. All those things that marketing does is to create this element of trust. My job, once the patient comes in is to focus wholly on that patient so that I fulfill the promise that was created by the marketing, but I'm taking care of the patient.

And my concern is that we've talked a lot and I think there is value to bringing some folks from outside the healthcare industry, but they've gotta be strongly supported by a team of deep healthcare experience. Who's then open to innovation, open to new ways of approaching things. But you can't just turn it over to somebody from outside the industry because they've had success somewhere else in the consumer, um, facing aspect of their industry.

They, they're not gonna understand the nuances of healthcare. They're not going to understand the, um, the incredible responsibility of that trust relationship that Bec begins the moment the patient. Starts to register. Yeah. And once that patient is chosen to receive their care in your system or is forced by, you know, showing up in your ED to receive care in your system, that patient becomes a wholly trust for your system.

Yeah, absolutely. So let me, lemme talk to,

Which will tell you when we're recording this show, even though it's gonna be released on Friday. But, uh, cardiologists say Apple is overselling its health rollout with F as f d a applauds, and it, it talks about how apple's, uh, touting their, uh, their watch as a detection system for AFib. Uh, critics are concerned that the f at the is unusual celebration of.

Which is central to apple's, the

many cases given warnings. Necessary and even lifesaving medical health. And it goes on and it cites a nurse whose daughter had, uh, kidney failure. And the Apple Watch, um, uh, predicted something that they didn't see. Um, and it, it in C N B C, you know, you know, users are, are telling me they found a problem, uh, with their heart they didn't even know existed.

And if

life.

C of, um, but doctors are worried that when used by million AFib, uh, could lead to unnecessary, even harmful medical care. That's why Apple's marketing of these stories on to card. Many people using Apple Watch might respond to detection of AFib by unnecessarily seeking treatment to date. The benefits of treating the condition have been proven only in certain at-risk populations such as elderly and hypertensive and diabetics.

Um, it's interesting because this post I, I saw this on LinkedIn this morning, and. Uh, and the people who commented on it were all physicians, and it was all, see, this doesn't work. See, you know, you know, it, there's no, uh, there's, there's no research studies, there's no, uh, you know, there's no proof that this is gonna work.

Um, but from somebody who's a technologist and somebody who's actually wearing an Apple watch, I see the benefits to the consumer. I understand that once they become a patient, I'm not, I'm not gonna prescribe a, an Apple watch and say, Hey, this is how we're gonna monitor your health. It's not there yet.

The consumer world, I, I would think it, it's a, it's a decent thing to, to have that little thing say, Hey, you might have AFib. Call somebody and talk to 'em. Yeah. Yeah. So my take is number one, apple has done a more thoughtful job than a lot of the app developers. A lot of the folks that, you know, there's, there's a lot of trash out there and we're aware of it and we want it to be cleaned up.

But I'm also aware that anything that increases societal awareness of their health and improves their focus on preventive health or, um, Altering their health status and their health risk profile. I'm all for. And so the Apple Watch has some potential benefit there. I don't care for practicing anecdotal medicine, so you know, the testimonials are always, I'm leery of it.

And so my physician colleagues, I understand their kind of backlash against that. And I understand the need for studies, but I also understand that getting a patient in who's concerned, 'cause my Apple Watch told me I have AFib. Also gives me as a primary care physician, a chance to talk to 'em about, yeah, and you're 35 pounds overweight and you're really more at risk for type two diabetes, and you probably have prediabetes.

Let's work on that and probably as I get you to do more exercise, this question of whether you have AFib or not will resolve itself. Now, having said, I don't. On an E K G, I can get the algorithm to read me as AFib simply 'cause my resting heart rate is 42 and I have a respiratory, uh, variation. So I'll drop as low as 26 and go up to 50.

And in doing that, I have irregular spacing of my Q R s, which is the little spiky part of the E K G. And the algorithm reads me as being in AFib when I am in total sinus bradycardia induced by my lifelong running. So I, you know, that's the risk, but, you know, let's talk about it. Patients, for the most part are gonna be able to understand, if I take the time to explain that to them.

Yeah. It's, it's, it's, I mean, my initial task, this was they're seeing doctors and they're saying, Hey, they're asking for unnecessary tests. Well, as the doctor. Is, you know, we can do the tests if you're concerned about these things, but lemme AFib,

don't see the downside. As a physician, my job is discerning. As the patient, your job is to get in when you have a concern. Here's where I think the doctors have a, have a really good point, which is, um, the analytics. The analytics have become a black box. You know, so what's it, what's it reading behind the scenes and then spitting out results to, to a patient and saying, Hey, you might have X, you might have Y.

And um, this is the area that I think.

And especially the data companies, the, the Amazon wants to get in, uh, Google's, I mean, they're in Google and Amazon are in, uh, Microsoft's in and you're gonna see a lot more pressure, I think, on really exposing what the algorithms are looking at and. And, uh, submitting those to, uh, uh, really to some, some academic rigor around are, you know, are these accurate?

Are they actually predicting what we think they're predicting? Um, because people are gonna start making, people can make mistakes. So can algorithms. And having them be behind the scenes and it's like, Hey, don't worry, we trust Google. They're gonna give us good stuff. No, no. I, I understand some of that's your proprietary information, but, um, if you're gonna be treating people that comes under the F D A, that be, if you're gonna be making recommendations and becomes a medical device, yeah.

They, they skirt that. Well, we're just making a recommendation to the doctor, but either way, uh, I think we're gonna see a push to Yeah, and they even call it just creating an awareness. As opposed to recommendation. Yeah, it's, it's, if I were bringing these tools into healthcare today, um, one of the things I would probably require is, alright, I, you know, I don't want you, I'm not gonna put me under N D a, but we need to be able to look at your algorithms.

We need to be able to look at how, how are you generating that green light? How are you generating that red light? Sure. And at the same time that we're talking about Google and Apple and others coming under that type of scrutiny. And, and I totally agree, we need to do the same as a medical profession with our care guidelines.

'cause so many of them are really just a rehashing of what has been historic care, uh, community care standard. But that doesn't necessarily mean it's evidence based. We need to subject our care guidelines to evidence based. Good research just as we are going to ask them to submit their algorithms to good validation research.

Then our patients benefit. I mean the bottom line always, and you've heard me do this before, I always come back, you know what's best for the patient. It's not a matter of, you know, me getting to do my procedure 'cause that's what I do. You know, a man with a hammer's gonna pound nails. Or me getting to make money or me getting to stand in front of my shareholders and say, here's the dividend.

And here, you know, we, we supplied this dividend. It has to be what's best for the patient. And we just have to always come back to that as our core conversation. I did that as the c i o with my team. I said, each of you is as much a part of the care team as.

The team finds inspiration in that, and I think our IT colleagues find inspiration in recognizing that that's who they are. But we across the industry have to keep the patient first in our mind. Back to the consumer centric, back to patient centric patient has to be the reason you're doing it. Yeah, absolutely.

David, as always, great conversation. I guess the next time we'll see each other is, is in the desert at the, uh, Scottsdale Institute and, uh, very much looking forward to that. Yeah, I'm looking forward to it as well. And, uh, we will get out on the golf course and show each other how little we have played and practiced our golf game.

for the.

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