This Week Health

John Halamka on Cloud and Machine Learning, CIO as Convener, CMS Big Announcements

Use cases are real, adoption is happening in the cloud and for machine learning. What the CMS announcements mean for the consumer in healthcare and how the role of the CIO has changed to a convener. Dr. John Halamka joins us for a fun look at the big announcements at HIMSS.

Transcript

This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.

 Welcome to this Week in Health It where we discuss the news information and emerging thought with leaders from across the healthcare industry. It is. Friday, March 16th. This week we cover big announcements from himss. This podcast is brought to you by Health Lyrics, a leader in moving healthcare to the cloud.

This is episode number 10. My name is Bill Russell, recovering healthcare, c i o, writer and consultant with the previously mentioned health lyrics. In, uh, in 2011, I became the c i O for a pretty large health system, 5 billion, uh, dollars, 16 hospital system in Southern California. In Southern California. I immediately realized, I needed some, some people with wisdom, some people to help me chart the course.

And so I asked around and people recommended I seek out the two Johns from Boston, uh, Glasser and Halamka. And lo and behold, uh, the two Johns were teaching a course at the Harvard School of Public Health called Leadership Strategies for It and Healthcare. And it would've been a great course if it was just the two of them.

But they also introduced us to, uh, some, some great people. Stephanie Real from Johns Hopkins. Uh, Blackford Middleton, uh, Dr. Tesh Al Gandhi gave a, a a phenomenal presentation on the value of the E M R. Uh, I was on that week. I was introduced to, uh, Ken Mandel as well, who, who helped me, helped shape my thinking around E H R interoperability.

Uh, it really was a wonderful, uh, wonderful experience. Today I'm joined by one of the professors of that course and one of the Johns, uh, c i o of Beth Israel Deaconess, Dr. John Halamka. Good morning, John. Welcome to the show. Good morning and what an honor it is. You know, as a 55 year old person, my next 30 years is devoted to mentoring those who will replace me.

So it's all about the students. Are you still doing that course? That was a, that was a phenomenal course. Yeah. And so, uh, although the, it has been shaped and shifted a bit because remember that course came outta the meaningful use era and now we're in the kind of post meaningful use era. So, you know, professors and topics are slightly different, but I'm absolutely in it every year.

That's great. Uh, so you're, uh, I'm gonna give a brief, uh, your bio's way too long to read on a 30 minute show. So, uh, two time c i o of the year. Um, the Harvard website lists like, uh, like about 65 publications that you've been a part of. I'm sure it's larger than that. It actually looks from that website, like you either retired in 2011 or they stopped updating it after 2011.

Um, but I, I love on that site that it lists your, uh, 1980 National Merit Scholarship. So they, they really captured all the things that you've, you've, uh, you've accomplished. Um, and clearly you're a prolific blogger under the, uh, geek Doctor on, on, uh, blog spot. Uh, life is a healthcare c i o. You also have a book by the same title.

Uh, so I'm wondering, uh, the blog, are you gonna, are you gonna change the blog to, uh, you know, uh, I don't know, geek Farmer or what, what, what's your, what's the, the, any, any changes in store for that? The blog. Fascinating question. Have you noticed that in 2018 the attention span of most folks seems to be reduced a bit?

Yeah. That's why it's a 30 minute podcast. Yeah. So in fact, you know, I've written thousands of blog posts and articles. But what I figured out is that people these days want tweets. They want Facebook, they want Snapchat. They want Instagram. So what you'll see is that although I'm still writing for the academic literature and writing books and articles and opinion pieces and that sort of thing, my social media presence has actually been reduced to, you know, sort of daily.

Here's a pithy thing you should learn about today. Yeah, they're a little different. Yeah, it is. It is a little different. Well, one of the things we like to do before we get into the meat of the show is just ask our guests, uh, you know, what's, what's one thing you're working on now or what are you excited that you're working on right now?

So you may know that I served Bush for four years, Obama for six years, and the current president not so much. And so I'm spending much of my time internationally. And so the Bill and Melinda Gates Foundation asked if I would help unify the data of Africa. And how do you deal with H I v, malaria and tb?

How do you deal with challenges of a mobile workforce? People whose names, genders, dates of births are probably not sufficient or accurate for matching. So my current work, which is really interesting, is deploying biometrics in Africa in a cloud-based blockchain backed mechanism to exchange healthcare data for h I V care.

So it's live in South Africa today. Next step we'll be expanding to Senegal and Mozambique. Yeah, that was a, you shared that in the, um, in the patient ID section and, and it's actually, uh, it is, it's amazing because generally speaking, I mean, it's, it's better than what we have in the US I think. I mean, I mean, you're really, you're matching the patient data.

You're, you're bringing that stuff together and, and, and bringing that data to the point of care, which is, uh, something that we still politically and for other reasons still struggle with in the US it's pretty amazing. But remember in the US we have extraordinary technology and medicine, but we have, uh, what I'll call psychology problems, right?

That is there isn't an incentive to share data. Or maybe as CIOs and see, you know, you had no gray hair before you became the c I O. Uh, you know, we're also stressed that we have to be so focused on, oh, I don't know, email reliability as opposed to interoperability. It just hasn't floated to the top of our priority at the moment.

Yeah, that makes sense. Well, here's what we're gonna use is our framework for, uh, this discussion this week. We have, uh, I, I just pulled the Modern Healthcare story. It has. It listed seven announcements. I'll, I'll read off the seven, but you know, if you have another one or, uh, that you wanna highlight, that's fine.

Here's the seven that they sort of highlighted. Big announcements from hims, Google announces, Google Cloud Healthcare, A P I C M S. Uh, CMA Verma announced Trump Administration's Mental Healthy Data Initiative, which includes mu changes and um, Uh, we'll definitely talk somewhat about that. Uh, Cerner will add Salesforce, uh, their health Cloud and marketing cloud to healthy intent.

Uh, launched, uh, United Healthcare is bringing Apple Watch to its motion wellness program, c m s, to push blue button 2.0 a p i for 53 million Medicare patients. And Epic has integrated nuances, AI powered virtual assistance, uh, into its e H R. And these were just the top seven. As you know, everyone sort of stores up their big announcements for that week, and there's, there's probably a hundred others, so, Um, here's what I'd like to do.

So what we're gonna do is I'll pick two. You pick two, and uh, I'll, I'll kick us off here. And I, I'm gonna cheat as I usually do. This is why I do a show so I can cheat. Um, I'm not really gonna focus it for my first thing. I'm not gonna focus in on one specific item. I'm gonna focus in on a trend that I'm seeing, uh, that's going on, which is.

Move to the cloud. 'cause if you look at, you know, the epic nuance that's, uh, AI powered, that's a move to the cloud. You have the, the, uh, Salesforce Health Cloud, that's a move to the cloud. You have, uh, Google's a p i and you did a session on cloud at the, uh, uh, at the Chime event. And so I, I think it's, it's kind of timely, kind of interesting to talk about.

And I'll, you know, I'll just, I'll sort of sum it up this way. Eric Schmid did the, uh, the, uh, opening keynote. And here's a quote, uh, that I, I pulled out of there. So he said, get to the cloud. Run to the cloud. Immediately. I can assure you that our data centers are more HIPAA compliant, more secure, more efficient, and better than your data center.

Only after you get there, well you have access to a host of new capabilities. And he went on to talk about access, that you are not gonna build out these AI and, um, machine learning capabilities. In your data center that you're gonna want to tap into the things that scale that the cloud brings. Um, also, Jonathan Bush did an interview, uh, Jonathan Bush from, um, Athena, uh, went on to talk about, you know, another trend, which is people want to, uh, they want to develop directly into these applications and we need new architecture in order to do that.

And he said, uh, I went from, we have a lot of other tech companies connect to athenaNet. Uh, to the base where we are now, to, you've got to actually let other people build in Athena. So. Uh, you know, the basic premise that I have is we, you know, cloud started off as an infrastructure play. So let's, let's get out of our data centers and let's do Dr in the cloud.

Let's, you know, let's go to Amazon web services, those kind of things. Then it moved to more of an application deployment model. Some of us did Workday, some of us did box, some of us did Salesforce, and the myriad of other and EHRs are now trying to do, uh, deployment models through the cloud. And, uh, now it's really changing to an architecture play.

The, the platforms are, are allowing us to create new types of applications. And in healthcare there's thousands of applications that, uh, still don't, don't live on top of these new, uh, models, and therefore they're not open. It's harder to share data, it's harder to, to do some things. So, you know, let's just start with.

My question for you is, you know, are we, have we finally moved beyond the fad stage of the cloud or are we moving to, you know, this is now something that healthcare CIOs should definitely have a strategy for and, and be moving forward in? I don't know, a little bit more of an intentional way. Well, so I think you've summarized the trends at HIMSS extraordinarily well, which is, you know, move to the cloud, embrace open APIs, have a suite of apps that surround your transactional systems and truly engage patients and providers in novel ways.

Uh, while, while, all along, while adopting machine learning, ai, these nor newer technologies while keeping everything reliable and secure. But, so let's ask, where's the cloud? Great. Where's it not? So, um, as a C I O I oversee 145 mission critical applications. Just deployed to 40,000 users, access 12,000 times a second at 450 locations of care.

You know, I'm living the dream like you did. Now ask yourself, how exciting is it to wake up in the morning and wonder whether your VMware slices are booting or not? So I, it's like not in 2018. Interesting. Right? I, I need to focus my day on how do I improve the doctor usability experience? How do I make that sort of patient stickiness to our healthcare system as opposed to the competitor's healthcare system better?

And if you look at sort of traditional architectures, let's take us, you know, You and I are probably a similar age. It's 1995. It's Fox Pro or Fox Base, you know, it's two, three tier client server. It's like you can't move that to the cloud, right? You need to have an architecture that says your web and mobile native.

You've got APIs and you've got this transactional system running in a place that's very easy to connect to. So for me, I've moved seven petabytes of patient identified data to a w s. I've moved my production clinical systems where I can, right. That Fox Pro thing. Still can't move where I can to the cloud and sure.

I've kept some on-prem. I. You know, the internet might disappear. I mean, it's not a joke. Right? Right. I mean, you're gonna get North Korea or God only knows what state sponsored cyber terrorist activity to take out, I don't know, D n Ss routing or something. Right. So, so you gotta have some things local, but I really, really try to move things out of my data centers 'cause I want to procure rather than provision services.

Right. And 2018 is exactly what you mentioned. Which is people say, oh, actually this is not a risk. It's a risk mitigation. Because Amazon has 50,000 employees instead of your five, you know, looking at security when badness happens at the internet, you think Amazon is gonna route first or you it's gonna be Amazon That figures out a route around the problem.

I. Right, so we're doing it. The BAAs are sufficient. The, uh, reliability is sufficient, but there's one area that's not sufficient and that is indemnification. So for fun, go call Jeff Bezos and say, Hey, Jeff. You know, let's imagine a bunch of Amazon engineers go rogue and suddenly, you know, I don't know, the H I V status of government officials is on Facebook.

Are you gonna indemnify us against that? His answer will be, um, I. No, . . Yeah. Right. So you've got a b aa that's great. And you've got highly reliable, highly secure infrastructure. But I'll tell you, it's just still early Google, Amazon, n t t data, all of them aren't quite yet to what I'm gonna call a single standard for paying you should badness happen to your data.

Right. And that's, uh, I, I'm not sure that's gonna change. We had . Um, we did have Workday, we did have Box. We did have Salesforce, um, uh, Microsoft as well. And we had bas with all of them. And when it came down to the Indem indemnification clauses, there's not a single one of them that would, would sign up for it.

And, uh, I don't foresee that change changing anytime soon. Do you. Well, I imagine there's sort two models to explore, which is I have a $25 million cyber liability policy from Lloyd's of London. Yep. So I say Amazon, Google, n t T data. Microsoft. Here's my data. Oh, and by the way, I will protect around that with a cyber liability policy.

But Michael Dell, back when Dell was doing hosting. Actually interesting thought said, you know, I can't make it an infinite indemnification, right? That would bankrupt the company. Right. Well, how about this? I'll agree to pay you three times triple damages, you know, over what your contract value is. So you, you invest a million in me.

I have a $3 million check headed your way if anything bad happens. Now, obviously that's not exactly sufficient. If I have, oh, I don't know, 2 million patients in that cloud and the, say, average cost when you consider litigation, media management, credit reporting, forensics, all the rest is 300 bucks per patient.

You know, 3 million doesn't go very far. . Right. You know, one of the things the, you talked about Fox Pro and, and, uh, we're both programmers probably at a different level. I mean, you programmed an E M R and, and I used to make applications within, within Fox Pro. The thing we loved about it is highly, I mean, you could customize the heck out of it.

You could make it do exactly what you wanted to. I think this is one of the drivers to the cloud now. Um, even though they are very. You know when you get Salesforce, you get Salesforce out of the box, but then you have this force platform on top of it, and now all of a sudden you can build applications that you can really customize the solution.

You can bring in IoT data, you can do a whole bunch of things to it. I think this is one of the. The new drivers to the cloud that, uh, that, that we're seeing is this. You know, and I guess Jonathan Bush also talked about this, that people want to be able to plug in new applications, new thoughts, new things into it.

And the cloud is giving us a new way to do that, that we haven't really had since FoxPro, to be honest. I mean, people give you the E M R and they're like, here it is, you know. If you want something, put in a, a request and maybe the the vendor will do it, maybe they won't do it. So I What are your thoughts on that?

Totally correct. So we call this at, uh, B I D M C, the e h r plus strategy. And what does that mean? So it turns out I have five clouds of E H R, right? So I got an Athena Cloud, getting a Clinical works cloud, a Meditech cloud, an epic cloud, some self-built clouds, and, but they're all fire enabled. Right. So what we say to this, you know, 26 year old in the garage, you know, you have this beautiful function that doesn't exist in the E H R.

And what if we get and put data from the transactional system using a JavaScript object notation from the cloud. Can you plumb that? And the usual answer is in a weekend. Right. You know, it's like, oh, here's a new or productivity application. Is Monday good enough for you? And that's literally what we're seeing.

As long as you cloud enable your data and your transactional applications with standard Argonaut based specifications on fire. That ecosystem of app developers can just rapidly deploy what you need. That's great. Well, we spent a lot of time on cloud. I'd love to love to hear what your, your first big announcement you wanna talk about.

I know this is gonna sound like the Gartner hype curve, right? But I thought the theme of of HIMSS in 2018 was machine learning, right? And you have to be careful. What is machine learning? It's not, you know, Watson is going to replace doctors. I mean, that's not what we're talking about. We're talking about boring prosaic stuff.

And let me give you an example of what I went live with yesterday. . Now, I hope you've never had to have surgery, but if you've ever had surgery, you know the doctor can't put a knife in you without a consent, have you? I mean, you were a C I O. You know what a nightmare it is to track down thousands of pieces of paper coming from doctor's offices all over humanity with a handwritten, wet signature on consent, right?

And so fine, you digitize this or that, and you have e-consent. It's just still a nightmare. What do we do? We asked Amazon to monitor our fax machines. Now what? What's that all about? We trained Amazon machine learning services to recognize consent forms, and so what happens, this is literally the application.

Amazon is a listener on our fax traffic, and when it sees a consent form, it knows how to identify the patient on the consent form and then writes via a fire, a p i a checkbox. Into the E H R that says consent received. That's all it does. So, wow. Suddenly no armies of humans searching stacks of paper and Amazon just does it for us with 99.9% sensitivity and positive predictive value.

Wow. Did that require you to move your data out, or is this just, I mean, you could have done that without moving your petabytes of data out to a w s. And, and the answer is it just turned out to be a little easier to plumb because I have my e h R in a w s so right. Connecting an Amazon machine learning service to an app that's running in a s is like minutes , right?

You don't need to worry about, there's no firewalls or VPNs or any of that other crazy stuff, but you're correct. As long as you move to this sort of a p I approach, uh, it could have been possible for Amazon's . App to call an a p i, even at a distance site. That's interesting. So, uh, you know, last week I said that, you know, some of the overhype themes were, uh, AI machine learning.

Were, were some of the things. You walked into a booth and they said, you know, we have, you know, we're using ai, we're using machine learning. Of course, if you ask them to distinguish between machine learning and ai, they really couldn't do, it's just, you know, well it also is indicative of who's working the booth versus whatever.

But, um, but. These technologies are real. We, we saw, I I, I count like about 15 to 20. Real world example. The three M booth was interesting. They have real world examples where they have applied these things because of the new, uh, the ability to, to move things through the APIs, the ability to free this data.

Um, and uh, and, and now the computing power that's available, it really is only limited by our creativity to start thinking about. What things that are very manual today that we could, we could then automate by, you know, plugging these things in or, or other tools that are out there. And they're, the great thing about the cloud is that you could, you literally could fire it up this afternoon with a credit card and you're totally right.

So when I talk about the machine learning applications we've deployed, they're literally like written in a weekend. And so here's another example. I built an A P I into our OR scheduling system, and I now have access to millions of previous or cases doctors and patients. I don't use the names, that's not important, but the patients say, what is the procedure or what is the comorbidity?

I. So what if you say, Hey, Amazon, um, bill needs an appendectomy. How much time should we allocate? Well, oh, bill is a 53 year old person with no comorbidities, and the surgeon is Dr. Famous who's done a million appendectomies. The answer is 25 minutes. So we just did that and what did it do? It freed up 30% of our OR schedule.

S So here's the, here's the question. So we have, you know, CIOs from across the board, so you'll have a c i o from a rural health system. You'll have a c i o from a multi-billion dollar large health system with a hundred million dollar budget. Now this used to be something that only the a hundred million dollar budget c i o could really talk about.

If, if, if you were, if you were the c i O of a small rural health system, are there things you could start thinking about and tapping into that you couldn't do before? Because this stuff is available. Right, and so I, we're an open source shop, so to speak, and that is everything we do. We open source to the world.

So you can assume, you know, fine, we might prototype something for you, but then it's gonna be available at Google or Amazon or other provider to just lift off the shelf with your credit card for, you know, 49 95. So I guess the one advice would be, Make sure your e h R vendor provides these fire APIs, you know, move to cloud hosting if you can, and then you can just take advantage of this library of all this other stuff.

And it is one final example for you. Uh, Beth is ridiculous going through a merger right now, $5 billion merger, 'cause healthcare gets better by getting bigger. Remember that And our, our philosophy is, even though you're gonna be running Epic here, or Meditech there. Run anywhere. Right? And so just lift them off the shelf, plug them in.

Done.

Uh, all right. Sorry, I, uh, had a technical glitch there for a second on the sound. So, um, you know what, let's, let's jump to, uh, your favorite topic. I know, I know you, you've worked in a lot of different administrations, and this is not really a, a left right issue on the political spectrum. This is really about interoperability.

We want better care, uh, through interoperability and, uh, I'm, I'm just pulling up the article from the, the magazine. So what I'm gonna cover is some of the announcements from, uh, CMS and.

Effectively transition. Uh, we cannot effectively transition to value-based care system unless we transfer all of.

I know we can get better care if doctors have all the information. I'm not sure if that statement specifically, but common ground would be the more information you have at the point of care, the the better care you're going to receive. And that's, that's the promise of interoperability. So here's, here's some of the announcements and I'm curious.

I'll just read some of 'em and I'd love to get your, uh, feedback. So, uh, so for data to flow freely, uh, so this is a quote from.

C m s, uh, administrator for data to flow freely. She said there would be, there would have to be an overhaul of meaningful use. And the full ballroom at HIMSS 18 broke into applause. Does that surprise you that they broke into applause at all? So meaningful use built a really important foundation.

Absolutely. I health, I, I firmly believe healthcare still would, would not be digitized if we didn't do mu. And stage one was great. I mean, Dave Blumenthal, John Glasser and the team put together a good floor. It started to unwind and unravel at about stage two, where then what ended up happening, unfortunately, is that every federal government department decided to make meaningful use its policy lever.

Oh, I think we should have implantable devices using universal device identifiers. We should record social determinants of health. We should stamp out Ebola. And every one of those was layered on top of mu, and so what ended up happening is it co-opted the agenda of every healthcare vendor and every provider in America.

What should have happened is we should have had, I don't know, stage one and stage one plus. And then stopped . Yeah. And so what we're dealing with now when we talk about stage three is it's just not relevant, right? We're living in a world of machine learning and APIs and clouds, and it's still with what are the 17 quality measures for diabetics?

You're going to, it's like, oh, stop . So, so, so instead of, so what they say is, uh, you're gonna see a series of proposed rule changes by the end of the year. Uh, should we just. Should we just say it's had its day and, and end it, or should we, should we try to modify it? So, so here was my complaint with both stage two and stage three.

It, in effect said, you must drive a Prius. Well, wait a minute. I, I, I have a volt. No, I have a Tesla. No, no, no. It has to be a Prius. Well, is the outcome that you should be able to drive a vehicle with low pollution? Well then let me buy what I want to buy. If I wanna use a skateboard, that's okay too. Uh, you know, I'll give you some exercise and that's why we need to scrap the current meaningful use construct.

And what we need to say is the outcome is that patients and families are going to have better engagement because we're building tools. But don't tell me what tools or how to build those tools. 'cause in my case, believe it or not, I mean, I've built 30 Alexa skills. So it's like you're gonna have Alexa on your desk and say, you know, make me an appointment with my cardiologist.

I mean, as opposed to what an mu may say is build a portal and have a checkbox. Well, no. So I love this idea. I. As you say, it's apolitical, it's not right, it's not left. I'll say, let's have an outcome we wanna achieve and then let the market figure out how we might solve that best with emerging technology.

Yeah, I agree. I'm gonna read a couple more things here, so, uh, continue to quote, we're changing to a new era of empowered consumers. I love the fact that we're finally using that consumer. Uh, the term, uh, we, you know, we can talk about that. So we're changing to a new era of empowered consumers. We are putting patients first and making sure patients have access to their healthcare data.

Uh, you're hearing that from the White House as well. We're very clear that patients should have their data and access to it in a timely manner because that will increase. Uh, actually, uh, this quote is silly at the end, but that will increase quality duplication and testing. Well, we don't want to increase duplication, so I, I'm sure it was whatever, but, but, but generally the, the thought is if we give it to the consumer that is going to help to change healthcare.

And, you know, one of the, one of the articles I wrote a while back, Is, I have this theory that if you did give the patient, uh, data to the, to the patient, if the patient had all of their data, and I, I, I love patient Dave and I, I, I've had 'em speak at our health system. Um, you know, I think it would, it would really change some things.

If, if I had all my data in every American I. Uh, had all of their data, I think you'd see a couple of ecosystems arise. You would have, you'd have cloud providers come in and say, Hey, give us your data and, and we'll add value to it. You'd have researchers come in and say, Hey, give us your data and feel good about yourself.

You're gonna help us to cure cancer. And you, you may even have pharma come in and say, Hey, give us your data and we'll give you money. I mean, it's your data. It has value to us, and we want to compensate you for the value. Um, are we at a point now where there's enough momentum behind this, or are we still caught up?

And you're a doctor as well, so are we still caught up in the, we don't want to give data to their, to patients because they don't know what to do with it, which is, you know, the Judy quote that I think she got caught on. But, um, but that is a, that's a sentiment that I, I found talking to a lot of physicians.

I don't wanna, I, I'm trying to protect the patients. If they had this medical record, they might make the wrong decision. Or where are we at on this? Sure. So I think you are absolutely right. The era of consumer empowerment is here and any restrictions on data flows are gone. Where Judy got in trouble and where I've got in trouble, I'll just tell you it's 'cause the intent of what we're meaning is just telling a patient their serum sodium is 1 39 isn't very exciting.

I have no idea what you just said. Right, right. As opposed to saying, ah, I'm gonna fluidly give you all your data, but I'm also gonna help you navigate the healthcare system, which is, here's how you make an appointment and here's how you get a referral to a specialist, and oh, here's a machine learning plugin that's gonna compare you to 10,000 people like you.

I mean, those things of value is, that's really what we want to have, not just a portal where you can read your serum sodium. So, so, absolutely. Uh, Beth is ridiculous. Been sharing notes with patients for five years. Everything about you includes you, and we're just started an initiative where you are writing the note that goes back to the medical record.

And so the doctor could say, oh, I think you're depressed. And you could say, no, you know, I'm just, uh, you know, not energetic and I, it's rainy or whatever. You know, you put in what you say, what you think as part of the medical record. So that's where we are. Wow. So, um, that is where we are. So, let's see. They also announced my healthy data and um, I don't know.

You know, let, let's just for a second and then I'll, I'll, I'll let you choose the last story. Whatever you wanna talk about. Uh, everyone's story, APIs around, like, uh, it's the cure to everything that, uh, that ever existed within healthcare, but we still have this data challenge, right? So, uh, my data, my health system is different than your data and your data from one physician to another.

Could be, could be a challenge. How much is data is, are APIs actually gonna solve? And how much do we still have a, a huge, heavy lift with, with our data to, to clean it up and, and get it ready to, to, to be meaningful when we actually move it? So you highlight a really important point. So if you read Tef fca, that trusted electronic framework and common agreement, it says, oh, we're gonna put APIs everywhere for everything.

Well, no, right? APIs are fine if the use case is query response. You know, I want to get my data from a doctor's office, our APIs useful for saying for the last 10 million patients like this, you know, what was the morbidity and mortality like, no. So what we need going forward is APIs for certain architectures and use cases, C C D A, payload transmission for others, bulk extracts and E T L for others, right?

So pick your technology based on the use case and application, and then you'll be fine. APIs are very important because it does allow this ecosystem of apps to evolve, but it's only one part of the puzzle, right? Well, do you have another, uh, story you wanna, or, or theme from hims that you wanna highlight?

Sure. And that is that the role of the C I O has changed. Totally. Right. So back again, since you and I are of similar age, you know, we were software developers and architects and we could tell you what RAM to use based on its transactional speed. Do you think any of that matters anymore? The answer is no.

What you need as a C I O in 2018 to be is a convener. You understand business requirements and strategy, and then you take that and procure services from multiple cloud providers and plumb it together. And so it's just so funny. I have an M I T engineering degree. You know, I had to be a doctor, engineer, politician economist to survive the 1990s, but today, Unbelievably, you'd probably best be a sociologist.

Right? It's all about people. Yeah. The, the role has changed to how can you help the organization to navigate change? And that is, uh, helping people to understand the vision for, hey, here's what's possible, and then bringing them together to have a conversation of, okay, if these are all the things that are possible, what should we be doing?

But should we be doing something different in the Boston market than, than they're doing in Southern California? Probably I. Our environments are very different and our communities are different, and there are things that are probably a priority here than that aren't there, but we're we're people that lead those conversations.

It's really fascinating to me. The other thing that's fascinating is I had a fair number of conversations at the, uh, CHIME forum and a whole bunch of the CIOs, the, that have been pushed into this operational role. And then you've seen these other roles sort of elevate Chief Digital Officer, chief Innovation Officer, and uh, And, and I'm not sure the c i o, the chief information officer knows what to do now other than, okay, well, my job now is to keep the E M R running to make sure the data center runs to have DR capabilities and even security somewhat, I mean, not the implementation, but the oversight of, of security has been taken away from them as well.

and they're, they're saying, okay, my job, they really have become more of a director of infrastructure and technology than, than a traditional c I o. I mean, what do you say to, to someone who's saying, I want to get out of that trap. How do I get out of that trap and, and how do I, I don't know, differentiate myself in, in that space?

Right. So I became a C I O in 1996. And as a C I O I was the Chief Digital Officer, chief Innovation Officer, chief Medical Information Officer, and the ciso. Right. And so what have I done over the last 22 years? I've actually, I'm the air traffic controller. I. But I have carved up the office of the C I O into five different components.

I mean, the ones we just enumerated, because that's the nature of how the work has to be done these days. So fine. Tell a C I O, you're a sociologist. It's a change management activity, and you're a convener and you have these experts working for you at these individual domains. You can't do it all yourself.

It takes a village. It does take a village, and it is, it is a larger job than any, and, and people should not be concerned that, hey, they just hired a Chief in Innovation officer and they just, uh, because they're very different roles. A chief innovation officer is working with VC and, and private equity and, and looking at deal flow and a couple other things, and as the c I O that also has to overlook security and whatnot, you just cannot do it all.

There's just no way anymore. So absolutely true. And so these days I spend a lot of time, as I mentioned internationally, so I'm working with entrepreneurs in Israel. I'm working with entrepreneurs in China. And so imagine the c I o who's worried about whether the E M R is fast or slow, and, oh, I've got this great new project in Wuhan.

It's like, uh, I can't pay attention to that. So that's why the innovation role has the freedom to explore these new things that are a little bit tangential to operations. Yep. Alright, well here's, uh, we're we usually close out with your favorite, uh, social media post for the week? Do you happen to have one or, or am I surprising you now?

Oh, well, you know what Harvard faculty say, The favorite post of the week written by me . Sure. What do you got? Right? And so you'll see a, a Twitter post in the next two minutes or so where I thought a, a very novel means of communication. I mean, this is gonna sound so silly to you, but the Northeast has had a torrential winter.

It's been horrible. I have to buy a new chainsaw. And so the guy at the chainsaw store, he emailed me a photo of a message on his Apple watch saying when my chainsaw would arrive. It's like we are now reduced to emailing pictures of Apple watches to each other. Who would've thought ? Oh man. That is, uh, that is a sign of the times.

My, you know, my post is a little more traditional. I guess I'll, I'll have to quote my own going forward. I, I mean, do you think that was a possibility? Um, I thought it was interesting. There's a, uh, HIMSS had a very lively, uh, Twitter feed during the event. They had, uh, a couple of polls. This one was what will the biggest impact to newcomers like Amazon, Google, Salesforce, and Apple and other traditional technology players entering healthcare, you know, what will the impact be?

And it had four options. Spur innovation, increased confusion, grow, vendor consolidation, and improved user experience. And. It looks like we're split. I mean, it's a pretty, you know, spur innovation. Sure. 30% increased confusion. Sure. 20 some odd percent improved user experience. Sure. 30 some odd percent. We, the, the answer is we don't know.

There's been so many missteps, and we're just gonna, we're gonna see as everybody else sees. So, uh, John, thanks for being on the show. That's, that's really all for now. Uh, please follow John at, um, on Twitter at Jay Halamka. And his blog, uh, geek doctor@orgeekdoctor.blog spot.com. Well, you, you stayed with Blogs Spot a long time.

That's been a pretty good platform for you so far, so good. Yeah, that's, that's great. So you can follow me at Twitter, uh, at the patient cio, uh, my writing on the Health Air website and health system cio. Uh, every other week I get an article out there. And, uh, don't forget to follow the show on this week in h i t and check out our new website this week in health it.com.

If you like the show, please take a few seconds and give us a review on iTunes or Google Play. And if you don't like the show, please send me an email, tell me what uh, you'd like to see us do. So please go back every Friday for more news commentary from industry influencers. That's all for now. Thanks so much.

Thanks, John.

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