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I think we saw a whole bunch of people who are tech entrepreneurs come in, look at healthcare and be able to say, this is a mess . But what they often failed to see is the complexity of the healthcare space. I have often said that healthcare is not an industry. It's an ecosystem, it's a whole set of intertwined industries.

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So welcome back. I'm Brett Oliver, chief medical information officer for Baptist 📍 health and Kentucky in Indiana. And I am very pleased to have with me today, Dr. Ray, Costantini right. As a physician entrepreneur in the digital space that I met when as a co-founder of bright.MD that we utilize their back self and I want to welcome Ray to the show.

Thanks Brett. A pleasure to be here. Our conversations are a blast and I'm looking forward.

Yeah, we were just talking off air so many times I've had conversations with Ray that I was like, oh, that's exactly what we want to record. So hopefully we'll have one of those today.

But I'm curious in one of the questions, I don't think I've really ever asked you specifically, but how did you get interested and get started as a physician entrepreneur in the digital space or just in healthcare in general?

Yeah, actually I have a relatively unusual path there, but in that I was actually, I grew up in a family of entrepreneurs and I honestly didn't realize how unusual that was until I got married and and got some exposure to folks, family that, that weren't like that. But my dad was an entrepreneur. My grandfather was an entrepreneur. I started my first company in a very different space, right out of high school. The thing there was, I didn't love the industry that I was in. I did well, and that enabled me to go and look for. Calling more of, of the location and that's where I got into healthcare.

And depending on whether you ask me or my wife, I either jumped in with both feet or head first and got my MD, but then once I was in the healthcare space and in practice, I felt like a lot of the challenges that my colleagues, the physicians and other providers were struggling with and certainly a lot of the challenges that patients were struggling with came because the system was broken. It wasn't solving the problems that people had. And I couldn't help, but bring some of that entrepreneurial mindset to it, and that just kept pushing me in that direction more and more.

I felt like I could just have more of an impact by combining together that entrepreneurial background and , with the clinical expertise had the real fortune of being able to work with a fantastic person and group over at Providence. Really my first entree into digital health built the digital health services group over there 'and really work with some fantastic, fantastic people.

And, and then that entrepreneurship kicked back in and felt like there was a lot of opportunity to be able to move quickly and impact more than one health system. And then that's where bright MD came in. Uh, It was really an opportunity to take some of the learnings I'd had from when I was applying. And and say, Hey, there's, there's a better way to bring value to everybody involved. So that's, that's kind of the lightning version of it.

Yeah. So you had some experience as an entrepreneur prior to healthcare. So this question I think, is particularly pertinent. So what does the physician. Or what did you find as yourself as a position brought differently to a company let's, use a startup for instance, but to accompany that others couldn't,

I think that's especially relevant, even more relevant now than when I got started. When I get started in digital health and as an entrepreneur in the healthcare space. It was one of those spaces. It was a space where venture capital was hesitant to put money in people didn't invest a lot in digital health.

It was kind of, if you were in the healthcare spaces, you were doing device, or you were doing pharma or diagnostics, but not digital health. And then as digital health became more W where the value in the opportunity became more apparent. I think we saw a whole bunch of people who are tech entrepreneurs come in, look at healthcare and be able to say, oh my gosh, this is a mess I can, like, I could give a blind monkey a stick and they could hit a way to be able to create new value here.

But what they Often failed to see and continue to fail to see in a lot of situations is the complexity of the healthcare space. And the, the complexity of the issue I have often said that healthcare is not an industry. It's an ecosystem, it's a whole set of intertwined industries. And, and I think that it's easy to see where you can create value as an entrepreneur. But it's hard to understand all of those entanglements know where the bear traps are at, where the skeletons are hidden and then be able to navigate those. And I think physicians can be uniquely positioned to be able to understand both what can be better and how to navigate through that kind of a landscape , and make truly valuable solutions.

Yeah. Before about these billions of dollars being invested. And you wonder, has anyone talked to a physician that this practicing medicine, because this will never, or this is going to be so complex or, the margin is so thin there, and then you're going to add this to that. Like, it just doesn't make any sense.

I'll tell you there's one that I hear all the time on playing on the VC investing side of things. And it's interesting to be able to hear some of these pitches from people. And one of the things they hear all the time is this is going to be so great. All we need to do is get the providers to change their workflow.

And I'm like, oh, we're already done. Like it's. and the thing is, they're not rolling. But they don't realize how much inertia there is around that. And I have seen more companies fail. We're going to, I'll give you a really big example. I don't know if we talked about this one, Watson IBM Watson was an interesting example of this.

I mean, did it, did it have the potential to bring value, help providers comb through all the infinite amount of information that's out there? Yeah, sure. But the thing is it took effort and it made the provider's job slow. And it only saw it solved a problem that was there in less than 1% of cases.

Most of the cases that I saw as a provider were ones I knew what was going on. I had a pretty high degree of confidence about what the problem was and how to be able to act on that. And it was a very small minority of them that didn't. And in order to make Watson useful, you had to slow down 99, or you had to slid on a hundred percent of your visits to bring value to less than 1% of.

And that was a great example of what doesn't work in healthcare, even though the value could be meaningful. It just, , the change in workflow. Equate to enough value.

there's probably some, a mathematician out there that could come up with an equation. Cause I would be willing to change my workflow if the results were dramatic to your point 99% of my patients, or, but where is that?

Where's that sweet spot. Is it 60%? Is it 35%, but I've even seen some I've presented to, my colleagues, certain applications that we want to add, say for ACC coding improvements or things like that. And we lose them when the presentation says, okay, I'll get to do is click here and it'll open up this window.

They're done. That's not my workflow like that, and I think it's that appreciation for the pressures and the other things that are being asked, at least in primary care. I can speak to that, that there are so many things that we're asked to do. They're all individually, very small, but collectively that's it.

And then I'm also supposed to take care of the patient with whatever they've presented themselves with too, in addition to it. So, yeah, that's. Maybe as a corollary to that, were there gaps, maybe you didn't because you came from an entrepreneurial background, but were there gaps when you got to healthcare as an entrepreneur?

You're like, man, I, this is not something that I, I know enough about. You we're bringing the clinical expertise, but then you already have enough entrepreneur background.

I'm, I'm a believer that if you're not a little bit uncomfortable and you, then you fully, you feel like you've fully understand the space you're in, then you're playing it way too safe.

And again, that might be part of that entrepreneurial mindset. I I'm learning stuff. I feel. Let me say it differently. The entrepreneurs and the executives that I like working with the most have got a healthy degree of imposter syndrome where they feel like they're not ready to be in the role that they're in.

That lights, a fire under them to get better. I feel that on a regular basis. So yeah, I mean, I'm learning stuff in every as often as possible. So I it's I don't know if I constrain it just to the entrepreneurial space or, or to the clinical side of things. I mean, I, I think it's just more of a mindset, but I, I enjoy working with people who bring that same kind of a perspective to.

Yeah, I actually I'll give credit. My, it was actually my VP of engineering at bright MD, Robert de Falco, great guy. And he had an expression that he used often. I picked it up. He said, when you're green, you grow and when you're ripe, you rot. And I always liked that when it was very, a very visual metaphor for that same thing.

I like that. That's good. Well, I guess along those lines, What do you think health systems, when you're talking about digital health space, where you're, what do health systems get right or get wrong about startups?

That's an interesting one. There is I, I, in some ways I think there's a little bit of comeuppance for me when I was at Providence. I was undoubtedly guilty of this at times as well. But I think that there can be a tendency for health systems to blame a less than successful implementation of a product external.

Rather than looking inward and recognizing where their participation contributed towards that. And I'm trying to, trying to not think about specific solutions, but more like what could make healthcare better? What can keep it from being the place where pilots go to die?

Let me, let me interrupt you and say, is it.

I think I'm getting what you're saying. So for instance, I have run into people, doesn't have to be in my organization, but are looking for a solution and the solution could, and probably should be operational, but they come with a tool and you've got the tool and implement that tool, but you're like, oh gosh, I don't think you'd get the operational side of this and what it's going to take to make sure this tool is utilized appropriately.

I think that's definitely part of it. I would even go so far as to say that that's an important symptom, but I would go deeper on the cause I think I don't think this is just health systems. I think this is something that many organizations struggle with. They see that there's a pain but they haven't clearly defined , what the outcome they actually want from it is.

Or the steps that are needed to be able to get there in a realistic way. And I think that that's something that's not uncommon like, I'll make one up that I'm sure we've never seen, I want more patients to use our portal and, what's the actual value that you want from that.

And do you think that that's realistic? Are you going to do that by forcing patients to come to the portal because that's where they're able to access information, or are you going to do it by bringing meaningful value through that , and like understanding the underlying motives and what you're really looking to achieve, and whether that aligns with the way that you're doing it.

I've seen a lot of, I've seen a lot of failures around. I seen a decent number of failures or challenges, if not failures and challenges around defining unrealistic early, especially early success metrics. We see people MBA, you know, you see people implement a startup tool and they will measure success based on adoption.

But then not roll it out in a way that enables adoption. They're doing. Where it's only available to a small member of people and you can't really put it on your website and it's not, it doesn't have all the integration that makes it easy to access because it's a pilot, but then you measure the success of that pilot based on. And that's not a fair metric. If you haven't set yourself up to meaningfully impact adoption, now you could set your expectations around we're measuring workflow. We're measuring integration. Like what does success look like? And have we run the right experiment to test , the outcomes that we're measuring for so.

Yeah, no, no, no, no. I think that's well said. I wondered too as having, come from some startups yourself, when you're dealing with health systems, do you think one of the deficits that they, I know it's something that I've learned and I'm, I don't know that I can do a whole lot about it, but you know, health systems tend to move slowly and start startups. A never-ending funding source, they've got to prove themselves out. Right. So where's that marriage. Do you see that changing? Do you see health systems understanding through innovation centers , and just different processes and, and things, trying to come up with things to move more quickly.

I've seen us as an organization lose out on an opportunity or two, because, we just took too long.

I definitely think. It there's two sides to that. Yes. I definitely see that as a challenge. And I've also seen health systems make progress around that. One of the examples I've seen, , there was a time when budgeting cycles were, if you didn't get in on the annual budgeting cycle, you were.

Wait 12 days, 18 months before you could get in on that. And I've seen health systems start to do things like have innovation funds that have a more rapid approval cycle for a dedicated pot of money that allows them to be more agile. Just one example, not the answer, but an example of that, the interesting challenge, the parallel on that is that then you have to be good at moving things from the innovation arena, into the operations.

And so I think that there's a stage that sometimes gets missed in that process. And again, I'm just talking about that specific example as an anecdote. But you know, you see, you see the speed up front, which I think is an acknowledgement of health systems recognition that they need to be better at that, but then you have to solve the next challenge.

And I've seen a number of of initial implementations fail because that process, that handoff between innovation and ops, , there was a lot of friction or there wasn't clarity around.

Yeah. I've seen it before where someone will have a, an application in play, the it projects. Per se that project manager off the case off the project.

And then it's like, well, who do we go to? And mistakes. We didn't identify that early on.

Here's actually an approach that I've seen again. I far be it. This is sort of like telling people how to parent it's a bad idea because it's different every time. But one of the things that I seen work well around that, that I think health systems as a whole can benefit from.

In working with earlier stage companies and honestly working with many of them with many projects, it's not just having a project manager, but having what I call a product. And that internal person, their job is to own not just the implementation, which is a project, but the ongoing success and the business metrics.

And the corralling of stakeholders and the success of the product that's been implement. And having them truly be all that longitudinal role. It's not time box, like project, it's an ongoing business ownership piece and the places where I've seen the most success, where health systems working with external vendors solutions it often comes from that internal ownership and the mindset that comes not just from project management, but from product owner.

Makes a lot of sense. If you don't mind, I'm going to shift gears here. Cause this is something I really want to get your thinking on. So, in the last couple of years we've seen the emergence of a ton of traditional just use that term broadly non-traditional players in the virtual care space. I mean, every.

Health plan has a virtual only option. And you've seen companies like best buy shift their business plan and include health care in that gosh, dollar general store, even CrossFit has a virtual primary care offering.

Honestly, I'm waiting for Jiffy lube to offer your virtual care while you're getting your oil.

Oh my God. It's coming.

Yeah. So I'm just wondering like some of it, I don't, you know, I also see statistics from advisory board surveys. This. The only one from like 75, 80 5% of virtual care was delivered by a patient's own provider or their provider group. So it's still a personal thing. It's still relationship driven and I don't see them selling relationships as much as access, but I'm just curious.

Do you think, where do you see the threats for a health system? Where do you see the potential partnerships? Both. I'm just, just curious your thoughts on all that.

I think it's, you're asking a really interesting question there, Brett. And in some ways I think the answer depends on how a health system believes that it will continue to thrive and be competitive in a rapidly changing landscape. I'll give it a little business case in a totally different industry that will depersonalize it a little bit. You remember back when Southwest was like, they were. And they launched and they were the only profitable airline. They were doing things totally differently. And, and they really were. I think that was part of what was interesting about Southwest was that they genuinely did everything differently.

There, they were flying out of secondary hubs instead of primary hubs and they didn't do assigned seating. And when they were hiring. Yeah, exactly. As a unified fleet, all of their planes were the same, exactly the same, which reduced their cost for maintenance and for parts. And, and in response to that unified, cohesive, comprehensive different model of airline operations, there was a sponsor.

You remember United. Yeah, probably not Maryland kind of rings a bell, but just barely. It was, it was United response to Southwest and they took a handful of the ingredients that Southwest had brought to disrupt the airline industry. And they're like, we're going to apply this to a subsidiary called Ted, and we're going to do short haul flights on secondary airports, but they didn't do most of the other stuff.

And everybody knows that for off west and nobody knows United Ted. And I think that that's one of the interesting questions that health systems need to be asking themselves is do they believe that they can wholeheartedly embrace the opportunity to truly do something? Different or they going to be doing window dressing around it.

And again, those organizations that are bringing in innovative digital solutions in the broader context of really rethinking how they're going to be interacting with patients it's not, oh my gosh, somebody put some urgent care clinics up in our market and we've now got competition and we are going to go compete, but rather, oh my God.

We're not meeting patient needs and expectations around access to care and fixed pricing. And we need to rethink how we're doing that. It's a different level of self reflection. That is, I think the answer to that question cause you're not going to compete.

Teladoc. And while I, maybe it's not the best example right now, but you know, you're not going to come. You're not going to compete with somebody whose entire focus is in that area. You're going to be able to compete by understanding your patient's unique needs and thinking about how you can deliver on that and what are the right ingredients to it?

My dad had a story that he would tell her. We're I think we could probably agree that the human being is arguably the most cognitively advanced species on the planet. We're, we're pretty good thinkers in the spectrum of things. And the question is why is it that with all that brain power, we can't manage to design a bird feeder that keeps the squirrels.

And the answer is because that nut is what the squirrel thinks about all day. Well, mom, and so thinking about where can you w what is your nut? What is it that you as an organization are going to be uniquely good at? How are you going to uniquely meet your patient's needs through a combination of internal services purchased solutions acknowledging where you're you might be feeding the tiger, the hungry tiger that's on your porch.

When I was at Providence, we got approached by services provided. They're like, oh, we'd love to work with you. And , we're going to be a great partner for you with , our innovative new urgent care services. And , we'll refer patients who we can't take care of back to you.

Is that the right thing to be doing, or are you inviting in a hungry tiger and keeping them at bay with the steak in your fridge? But only allowing them to get bigger and stronger and then take away. A much bigger slice of what might be strategically valuable to you. They're hard questions.

I mean, these are things that we could spend a lot of hours talking about, but I don't know, are those, is that it is that a directionally helpful answer,

a hundred percent, a hundred percent. And I do it, and it's obviously very. Organizational specific in terms of, what you're dealing with. What's your market forces are it's different in Kentucky than it is on the coast, at least, right now. But I do think it's, it's something. Each organization needs to face and look at it rather than a problem to solve which it is. But it's also an opportunity. It's amazing how the patient experience, which has always been a part of our care, right.

That we want to make sure they have a good experience, but it's not been so much in the front of our face right now. And I, I think COVID,, and some of these digital services, the floor has been really. Tremendously. And I love the,

the bird feeder story. I, and I, I really, I think we probably should end with that one right now, but if anything, a terrible, cause I think I'm going to have to have you back.

Cause we're just getting revved up here.

It would be a pleasure. Like I said, Brett, I always enjoy talking with you. I can only hope that it's something that has been entertaining for you and at least for one or two other people out there would love to.

So yeah. Well, I appreciate you being here.

Thanks for.

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