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Dr. John Halamka joins us to discuss Promoting Interoperability Final Rule and what are hospitals expected to do about the Social Determinants of health factors in their communities. This plus a pragmatic look at IT.


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 Welcome to this Week in Health It where we discuss the news, information and emerging thought with leaders from across the healthcare industry. This is episode number 35. Today we talk to the to the geek doctor, Dr. John Halamka, c I o, for Beth Israel, deepness about the final rule for promoting interoperability, social determinants of health, and some pragmatic questions around health.

It. This, uh, this podcast is brought to you by Health Lyrics. Health systems are moving you to the cloud to gain agility, efficiency, and new capabilities. Work with a trusted partner that has been moving health systems to the cloud since 2010. Visit health to schedule your free consultation. My name is Bill Russell, recovering Healthcare, c i o, writer and advisor with the previously mentioned health lyrics.

Uh, before I get to our guest, I wanna make a quick note, uh, so everyone is aware of the great resource for your IT teams this week in Health id. It has a YouTube channel, easy for me to say, with great insights from industry insiders, short segments and complete episodes, all curated for easy access. Every week we had another seven short videos and the entire episode.

Over there. So right now we're at around 300 videos. Check it out today, at this week in health and share it with your colleagues. So today's guest joins us, uh, from the home of the first place, Boston Red Sox, John Halamka, C C I O, for Beth Israel Deaconess. Good morning, John. Welcome to the show.

Well, uh, happy to be here. And remember, I am also a red stock, red stock's a medical All-star. So, you know, I can send you pictures of me on the Fenway big board. Wow, that's pretty, uh, that's, that's pretty impressive. So you, it is amazing when you go from, uh, from ballpark to ballpark how much healthcare advertises and.

Is is a part of the baseball program. So Beth Israel is, is pretty connected with the Red Sox. We are the official hospital of the Boston Red Sox. There you go. And the closest emergency department. So if you are hit by a foul ball, you come to see me. I. And I'll tell you what, I, I've been to a couple games this year.

Um, those, those stands appear to be getting closer and closer to the field. I mean, it's, it's not uncommon, I would think for, uh, for people to get hit by a foul ball these days. I do take my glove now 'cause some of those foul balls are, uh, come screaming into the stands. As you might imagine, we've done the analytics and the analytics.

This is actually true. Looking at the cohort of those who visit Fenway Park over the last 10 years, what is the highest risk factor for traumatic injury? Answer wearing a Yankees t-shirt, . True fact. That's, that's not a, uh, that's not a surprise. I, um, I, you know, short side note, I went to a playoff game at Dodgers Stadium and uh, and it was the Cardinals against the Dodgers.

I'm a huge Cardinals fan. I wore my Colonel's jersey. Uh, we had to leave after the eighth inning, uh, because we came back and scored, I think six runs against Clayton Kershaw. And, uh, people were saying things to me that I'm glad my kids were not around, uh, to hear. And my buddy who I was there with, looked at me and said, uh, we should probably leave now.

And so we left, we left in the eighth inning, uh, out of, out of safety reasons. So that, that is a, that is a legitimate health risk wearing the, uh, the rivals shirt to a baseball game. It's true. Uh, you know, the last time you were on, we didn't get to talk about this, but tell us a little bit about, uh, Beth, Beth Israel.

Dea, you've been there a while. Uh, you know, what's, what's the footprint, uh, what do, what's your focus? What are you guys doing? Sure. So I have been at Beth Israel Deaconess since 1996 as an emergency physician and as an IT leader since 97. And over the course of time people say, well, wait a minute. How could you stay in one organization for that many years?

Well, think about it, back in 96, 97, machine learning was impossible. Um, it was hard stability, reliability, storage networks, very challenging. So those first five years were all about building infrastructure, the predecessor to today's cloud. Um, and then, oh, security became an issue. And then years of security and keeping our systems and data integrity good.

Oh, and then how do I think about apps and how do I think about emerging services and integrating those and interop.

Or five years long has been actually a totally different focus. So now what's next? Well, you can imagine healthcare gets better by getting bigger. So they say it seems to be the trend throughout the country that mergers and acquisitions, community, hospitals coming together with academics, independent physicians joining practice groups, that sort of thing.

Well, in Boston, same things happen. So we have a $5.5 billion merger that is from Beth Israel Deaconess and Lahey Clinic, Mount Auburn, new England Baptist, all coming together. And that will pose a set of interesting interoperability challenges. How do I coordinate care across 7 million people and do so in 450 sites of care that are going to be running several different EHRs.

And so it's more than just a few data elements for meaningful use. It's actually ensuring that you are getting quality and safe care at the right time at the Right, right. Just freshly merged institutions. Right. So, uh, you know, just, just a quick side note and question on that. So are you gonna have the same e h R across your acute care facilities at least, or is that not gonna be the case?

So think about this, regardless of your brand loyalty, epic, Cerner, Meditech, Athena, eClinicalWorks, when a merger and acquisition happens, day one, you're gonna have heterogeneity, right? And so you can imagine Lahey Clinic Epic based, so it'll have a cloud of Epic. Um, my community hospitals all Meditech based, so have a cloud of Meditech.

Beth Israel Deaconess, self-built cloud of Beth Israel Deaconess self-built. So you can look for the next couple of years and you know that you're gonna have to deal with not a hundred different e H r, but three and, and you know, data sharing across those three. And then sure, time will tell based on how the market evolves.

Will that become two? Will it become one? It's a little early to know. I. Yeah, that's interesting. So, uh, the, the, uh, I would love to just go into that for the next half hour, but, but, uh, but we're gonna talk about some other things. So, uh, could actually, last time you were on, we talked, uh, you shared about the, uh, gates Foundation, the work you're doing in, uh, in Africa.

It it, can you give us an update on, on what's going on there? Sure. So the challenge in South Africa, 65 million people, 16% of the population is H I V positive and the challenge of coordinating care across what is a very heterogeneous country, right? There's urban, there's rural, there are issues with infrastructure, network bandwidth is expensive and slow.

And identity management, who are you, is actually a challenging question because names are misspelled. Workers move around. So with the Gates Foundation, we took the the process of care delivery and broke it down into several, what I'll call APIs or core functions. So core function one who are. So we'll do identity management and we'll do it based on biometrics.

'cause name, gender, date of birth, match doesn't work so well issue somebody identity cards, hard to know, but biometrics, if I say I'm gonna take, you know, fingerprints I scan, you know, retinal or IRIS, um, palm vein geometry or whatever. Is the biometric of the future, but build a system by which I can link your data by biometrics.

That's an interesting infrastructure. So sort of a p I. Number one is a general biometric infrastructure, and we've deployed that. In the right to care clinics and now can tag your H I V laboratory data to you. So you just walk into a right to care clinic and it says, ah, here are the last five viral loads that you've had showing your medication is working very well or not.

So those are problem one. Problem two is how do I share the data with a patient, right? As we'll talk about, I'm sure there's this increasing trend in the US of patients getting access to their own data, their notes, et cetera. Well, hey, bill, do you have an iPhone 10? Well, imagine that in South Africa, my lowest common denominator is the Nokia flip phone you had in 1997 running on A G S M network.

Maybe. So we've had to create a medical wallet for the patients that runs on a feature phone over very low bandwidth. And that's, uh, something we've deployed. We did a lot of usability testing and keeping a, a good number of folks in South Africa on the team really helped us what the needs assessment was.

And then the final question is, how do I deal with population health and data aggregation and look at variations in care quality and understand trends? So what we're working on currently is, is how do you expand what our early work on biometrics and this, uh, medical wallet to something that's gonna help for countrywide population health analytics.

And that of course could be machine learning. And it could start in South Africa and scale to other countries. So what's the platform? So we're starting to think through that. Awesome. Well, I'm looking forward to, uh, you know, just continuing to get updates on that. That sounds fascinating. And we talked a little bit the last time of why, you know, those things, uh, elude the United States Health System for, you know, privacy and, and different political reasons and whatnot.

Uh, and sometimes it's, you know, that the, the environment. The cultural environment and the political environment will give you the opportunity to do things in Africa that you couldn't do here. And hopefully prove, prove the concept out, get the, uh, get the statistics and bring it back. Bring some of it back into the states will be interesting.

Um, so on our show, we do two segments. We do, uh, in the news and Right. You clearly.

Did I lose you or are you still there? Did you have me? Yes, I'm still here. Oh, okay. Um, I'm sorry. You know, this, this, uh, internet thing, sometimes it's not as reliable. We don't have, uh, quality of service across this line. So, um, alright, so let's let, let, let's move on. 'cause we, we, we do have a lot to talk about.

So on our show we do two segments. We do in the news where we each pick a news story and discuss, and then we do soundbites, which is a series of about five questions that. Uh, I, I, I wanna pose to our guests. So you have picked the, uh, probably the most important story of the week, uh, which is the, uh, c M s Finalizing Promoting Interoperability rule.

So I'll let you kick it off with the, uh, with the first story. And if you could summarize it for us and, and we'll chat about it.

Is the operability program so important? So, remember, as chair of the H I T Standards Committee, I was there as meaningful use stage one and two rolled out. They were wonderful in that they built a floor for functionality, but they got a little cumbersome. And why did that happen? Because the meaningful use program with its stimulus and its penalties and its certification was so effective it became a policy vehicle.

And so I, I'll make this up because it's not exactly right, but if the F D A says, oh, we wanna track medical devices. I know we'll put that in meaningful use, and the c d says, Oh, we'll put that in meaningful use. And CMMS says, oh, we want 20 new quality measures. We'll put that in meaningful use. So by the time we got to the end of stage two, it got to be very challenging to figure out what you're measuring, who does what, and how much time it would take for the doctor to even do it.

So what Promoting Interoperability program says is, let's scale back. And think about just the few things we wanna do. Really well create some really clean measures and let's offer partial credit. It's right. It's not on or off black and white. If you as a hospital or doctor's office are making progress and your trajectory is good, that's fine.

So what it says is, oh, let's pick e-prescribing and opioid, uh, what we'll call interventions to reduce the opioid crisis. And so that's sort of 0.1. It's. E-prescribing, electronic prescribing controlled substances. Query the prescription drug monitoring program, verify your opioid treatment, and some are bonus and optional, and again, partial credit is okay.

So that's 0.1. Point two. Referral management. Although we had in stage two, the idea of, I send a summary to you, there wasn't really the incorporation of that summary and it's closed loop referral. So you get referred to a cardiologist, you see the cardiologist. The cardiologist never tells your P C P at the plan.

Well, how useful was that? So again, there's gonna be a bidirectional data exchange and incorporation close in the loop and partial credit for progress along the way, providing patients and access to their data, including notes. Do that via APIs. So anytime an app comes knocking the data is sent to the patient.

That's all good. And then public health, syndromic surveillance, immunizations, case reporting, public health registries, clinical trials, those sorts of things. So instead of saying there's a hundred measures and all these different complexities, it's four with partial credit, a hundred points possible. If you get 50 out of those a hundred points, no penalties.

So this is really streamlining the program, focusing us all. I said I think it's a very good approach. Yeah. So there's, uh, you know, we actually covered this in a previous episode when they, uh, proposed it, but it's, uh, here's a handful of the things. So, um, uh, each are reporting period, minimum of, of continuous 90 day period.

Um, in, in the calendar year 20 19, 20 20, 20 15. Uh, e H R CERT is what's required. Rule finalizes, uh, new performance based scoring methodology, which you've, uh, discussed a little bit, which meant to be less burdensome. C m s is finalizing, uh, two new e e e-prescribing measure really focused on op opioids, um, changes.

Uh, let's see. Oh, and the changes to the measures, which again, you've talked about. Uh, removing a total of 18 measures and Deduplicating 25, which is huge. Uh, and then the other one, which is interesting, require hospitals to post cost information on the internet, uh, in a machine readable format. Clearly, we're not covering everything.

It's 2,600 pages. Uh, have you had a chance to read it yet? Of course in detail and realize that 2,600 pages, like any of these regulations, 90% of it is preamble. Right. So that's you, you can actually get everything you need to know by going into the appendices and looking at the tables. Uh, 'cause it's really justification for why they did what they did.

Yeah. So it's interesting. This is interesting to me. But, uh, let me ask you this question. So these things generally come out mid cycle. Nobody has a financial calendar that ends in August and starts on September 1st and right. So this, this is hitting Beth Israel right now. This is the final rule. Um, give us an idea of what process you're gonna go through, uh, to generate the projects necessary to be compliant and to, uh, and to do the things you need to do to, uh, move this forward at Beth Israel.

So here's the, the, uh, Don Rucker at O N C recognizes this, and this is why they put in that 90 day, 2019 requirement. So here's what it means. So here it is, September of 2018, but

You don't have your certified E H R in place until October 1st, 2019, right? Because you have a 90 day evaluation, and as long as it's in by October 1st, 2019, you can get your 90 days. So all, I mean, it turns out our fiscal year is October one to September 30th. So this hitting in August turned out to actually be good for us because I was able to program all the interventions into the f Y 19 budget, and I actually don't execute on any of the stuff until F Y 20.

So, so that for us was okay. So you can, you can get ahead of it. You have gotten ahead of this and, and in reality, we're using the 2015 cert. Most EHRs are there. Of course you have a homegrown one, so I guess there was some work for you to do. Yeah, and so we of course, were the first E H R certified back in the meaningful use stage one.

All the functionality for the 2015 cert already, we just haven't gone through the process, so that's fine. It's now in the f y 19 budget as, uh, the staff time necessary to take what is existence software and to go through the cert process, which we've done multiple times already. So, um, so let's, let's talk about, you know, directionally, uh, what they're doing here, what the O N C is doing here, what C M Ss is doing here.

So, you know, you go from administration to administration. How much does the change in administration change the direction and focus of O N C, do you think? What's fascinating, isn't it, that you know, I've served Bush, I've served Obama, and you know, certainly stayed in touch with everybody who's on the, the current committee, the Federal Advisory Committee, and the Trump administration.

And there's a remarkable consistency, uh, and that is sure politics change. Really the trajectory of it doesn't so much . So a lot of the same people who were at O N C back in the Obama administration are still there, Steve Pozak, John White. So they are diligently moving us along a rather consistent program.

And in fact, sort the theme of the current administration is less regulation, less burden, all the rest. But the themes of what we're working on are fairly consistent. So I don't feel like there was a revolution here. It feels like an evolution. Yeah. I mean, the, the only thing I see that's a little slightly different in this is, uh, again, the, the bent being towards sort of free market.

It's, uh, we believe that access to information is, is critical. Not that interoperability is always about access to information, but this, this whole thing of let's. 'cause that's sort of a free market mindset. If we start publishing costs, there will be transparency into how much something, uh, is, is, is going to cost somebody and how good the doctor is or how good the system is.

And I think that's one of the first steps for them in seeing this not as a universal healthcare program, but as a more of a free market program. We'll, we'll have to see how this plays out. Um, you know, the, the levers, the , the levers of the government pools do not happen overnight. They, uh, they generally take many years to play out.

So by the time this starts playing out, there's probably a new administration and, and change. And that's one of the harder things to really, uh, for health systems, CIOs and health systems in general to sort of adapt to is the constant change in the regulatory environment. Uh, costs money and cost, resources and time.

I mean, how. I mean, can you talk to that a little bit? How do you, how do you, uh, prepare for that? How do you adjust for that? Sure. So governance is the key issue. So, um, I have since, you know, my earliest days as a C I O had a guiding coalition of doctors and nurses and pharmacists and social workers and administrators who meet.

On a monthly basis to understand, well, what are the strategic imperatives, regulatory compliance imperatives, um, what is it we need to do? If there's a sentinel event for safety and quality, how do we be impactful? So I had the hard discussion with them in 2009, think I'm sorry, but for the next five years, all of our business imperatives are going to have to be put on hold because we have ICD 10 meaningful.

Use the HIPAA Omnibus Rule, the Affordable Care Act. You must do that. Right, no choice, right? Because otherwise we're all gonna go to prison, . And so the governance group said, uh, you know, ICD 10 is not a very sexy project. Are you telling me we're gonna codify, flaming water skis, falling satellites and chickens hitting you on the head?

And I said, uh, Yeah, , but must do. And so, but wait a minute. I have this pet project that is going to impact, you know, 25 doctors, sorry, and the governance folks gave me the air cover to focus on ICD 10 and those things that weren't that exciting, but were must dos. But, so then here we are in this era, as you described it.

Out of that regulatory must do era and into a, oh, the private sector has to take a lead. You might have certain outcomes, you might have value-based purchasing or whatever, but how you do it, it's up to you. And my governance committee has now said, ah, well fabulous. Let's catch up on all the unmet needs of the meaningful use era.

And oh, here are a couple of strategic things. Oh, and by the way, we'll make sure that what you do aligns with the future, where we're paid with risk contracts, but we're gonna do it our own way. And that's okay. And as you point out, if five years from now we get back to a oh re.

Story directed process committee will help me through that. Yeah, absolutely. All right, so let me, let me take us to the next story. And, and, uh, the genesis for this story, to be honest with you, is, uh, I was looking at a conference that I'm getting ready to go to and someone was gonna speak and they had this title, catchy title of why your zip code may be more important to your, uh, to your health than your genetic code.

And I thought I remember that from somewhere. So. I went to the all knowing Google, and uh, sure enough, you know, there was a Harvard Business Review article. There was a, uh, uh, there was a, and, and there was a Huffington Post article, and that's the one I remember reading way back in the day. And it was circa 2009.

And so I wanna discuss that a little bit with you. Uh, you know what's changed since 2009? I know it's, it's becoming an ever more hot topic and, uh, you know, Boston's an epicenter for some of this. So let me, let me just summarize the article real quick. This is 2009 Huffington Post. Why your zip code may be more important to.

Uh, Robert Wood, John Johnson Foundation, uh, did a study and they looked at social determinants of health, and they had a few facts. And here are some of the facts. Evidence suggests that medical care accounts for 10 to 15% of preventable early deaths. Some Americans will die 20 years earlier than others who live just a few miles away because of differences in education, income, race, ethnicity, and where and how they live.

College graduates can expect to live five years longer. Those who do not complete high school, middle income, people can expect to live shorter lives than higher income people, even if they're insured. And people who are poor are three times more likely to suffer physical limitations from chronic illness.

In other words, as it relates to your health, our zip code is more important than your genetic code. So, John, you live in Boston. It's fairly affluent, uh, has its pockets, it's fairly fluent, and, uh, uh, you know, in a progressive city with a universal healthcare, uh, are the people of Boston healthier today?

They were in 2009. Let's start there. Are the people in Boston healthier today than they were in 2009? It's a very complex question. . Yeah, and so let give you a preamble and answer it directly. So you know, I've been a vegan for 25 years. And so I eat nothing but plants, right? And, and so no, I don't eat eggs.

No, I don't eat fish. Those aren't plants. Uh, and so what does that mean? Because I'm a vegan? Well, it means my cholesterol is 72, my blood pressure is one 10 over 70, and my body mass index is 21. And everyone says you're gonna live to a hundred, but why would you want to? Uh, but so of course, shouldn't it be rational that you should go to your insurance company and say, insurance company, I get a safe driving discount for getting no tickets.

How about a safe eating discount for, for being vegan? The insurance company says, um, that'd be no . In fact, what we need is people like you to fund all the people who are eating fast foods every day. So thanks. And so we haven't in this country had an alignment of incentives to change some of the lifestyle issues that you mentioned, and whether that's zip code or what you eat or how you act.

But what's changing and why do I actually think things are getting better in Boston? So not only, yes, we have this universal healthcare coverage so that there's a penalty. If you don't have insurance, that's good. But what we're seeing is the move to value-based purchasing then move to risk contracts with both upside and downside is so extensive in Boston that today, September, 2018, 80%.

Of the reimbursement of Beth Israel Deaconess services is risk, contract, or value based. So what does that imply? Well, that implies we better have an A C O that's looking at social determinants of health, right? If you are living alone and you don't have access to the right food, the right transportation, or an air conditioner, you're gonna be a high cost utilizer.

So we actually need case managers and care navigators and visiting nurses to deliver care in your home to you that keeps you healthy because we are now at risk for your wellness. And so I spent 7 million last year on just building out all the infrastructure necessary for that care management care navigation, visiting home nurse service.

To keep people healthier in their homes, incentives have changed and therefore our business has changed. Yeah, that's fascinating. So risk, and, and that's really true in the, in the Orange County market as well. Uh, you know, Kaiser, uh, Takes on the risk. And we heard this when I talked to, uh, mark props from Intermountain.

They have picked a zip code where they're going to assume risk and, uh, sharp healthcare out of San Diego. Uh, they have a significant amount of risk and they, they act differently. I mean, they really do that assuming risk takes them away completely away from fee for service. So then their, their economic incentives are different.

Um, so let's look at this from two perspectives. One is, Uh, you know, they're not in Boston, they're not in Massachusetts. How can healthcare organizations, um, you know, fund, uh, is, is getting risk contracts the only way to really fund being a part of social determinants outside of the altruistic nature of wanting a healthier community?

Or are there other ways to fund really the, these, these social determinants projects? Yeah, and so again, a very complicated question. Um, so for example, um, I recently took a bunch of engineers from a, from an industrial.

Into my mix. And the industrial engineers said, wow, you know, we wanna create products and services for consumers that will help consumers manage their own health. And so I wanted to talk to a couple of patients. So they went over to this homeless gentleman and said, what is your favorite wearable? And he said, Socks, , and so we have to be a little careful because there are the consumer driven products that will help with social determinants of health.

The most needy of that are, are our patients are unlikely to probably buy and manage their own health well. And so that's where I think this idea of risk contracts, Medicaid, ACOs are going to really help with that. Um, there may be models in the future where, uh,

Healthcare and accelerate social determinants issues regardless of reimbursement to the provider. But for the moment, it does seem to be very dependent on the way a provider is reimbursed. Yeah. So c v Ss is in your backyard and their, their, their pitch, if I understand it correctly from the conference where I heard the gentleman speak, uh, is really to step into that care navigator, be that first point of contact, be that

Uh, uh, almost primary care physician, but helping them to navigate these complex health systems like yours. Um, are you partnering with them or where do you see them fitting and, and how are, how are they going to mesh into the environment that you described? So we have no specific partnership with C V Ss, Caremark, Walgreens, et cetera, but we work very closely with all these organizations in our ecosystem because with a risk contract, they say you need to understand inpatient and outpatient and ED and urgent care and SS N F, and Pharmacy and all these other kinds of options and make sure that they're the patients.

Are given the right treatment at the right time, in the right place, at the right cost. And, and so why do I think that what c v s Caremark are thinking is good? Well, so my, it's a quick story for you. Uh, some years ago, my wife was sitting at the, the, uh, dining table with my father-in-law. My father-in-law began speaking in word salad.

Re total nonsense. He had no issues with cognition or movement. It just, the words coming outta out of his mouth were random. And so what does she do? She calls me, I say, okay, he's having a stroke and broke his area, and it's expressive aphasia. What we need to do is get him to a CT scanner at a local community hospital to see if he has a bleed.

He doesn't need academic healthcare, he doesn't need a tertiary referral center, he just needs a CT scan. And so we go to the lowest cost of care CT scanner that's closest to our home, and then do a telemedicine Telecare connection to a neurologist expert who interprets that and delivers the right care at the right cost at the right time, and he did totally fine.

Now my wife called me . That's not a very scalable model. If every patient has to call the physician and the family, well, can you, can you share your cell phone number so that we can try to scale it and see how it goes? Oh, perfect. Yeah. And, and so, uh, the idea that there is this care navigator that directs you to the appropriate quality, complexity and cost.

Is really a needed function. And you know, some of that'll be human, but I also have to imagine over time we'll develop machine learning models that'll help a little with that kind of thing. And, and remember, machine learning is not gonna replace doctors or anything. It's gonna augment care delivery so that everyone can practice at the top of their license.

And so what do I mean by that? So here, let's use an example that you can't possibly see. But, uh, so, so it turns out there's a spot right there. That spot is brown and it's circular. And it's flat. Is that skin cancer? It's been there for 20 years. It's homogeneous in every way. No, it's an age spot. Now, it turns out, whether it's Google or Amazon or some startup, you know, you can actually take millions of dermatological photos and suddenly put a probability on a novel photo, whether it needs a consultation or not.

And so that sort of thing suddenly will help our dermatologists get the right cases to review and the PCPs to know when to review and that kind of thing. So, so I just have to guess that c v s Caremark and the like providing services, augmented with guidelines, protocols and machine learning is a really good future approach.

I was with somebody this week and we were talking about this, and they're, they were, um, they were saying, you know what Doctor gives the most referrals in the, in the country. I'm like, well, it's impossible to answer. He says, well, not really. The, the doctor that gives the most referrals of anybody in the country is Google.

It's Dr. Google. And, and, and we start talking about that. It's like, you know, people will type things into their search bar that they won't even tell their physician, that they won't even ask somebody else. And, and a lot of times, you know, hey, Father or father-in-law is, is is speaking, uh, you know, word salad.

Um, their first inclination's gonna be Alright. I'm gonna, I'm just gonna, Hey, Siri, this is happening. What, what's going on? Um, so how do you think about that? Oops. I said, Hey, Siri, and my phone went. Um, but the, uh, how do you think about that as your. To develop the next round, knowing that in, in the Boston marketplace, in your marketplace, people are going to consult Google, and what you want them to do is as quickly as possible, get from Google to a, uh, a qualified care navigator or physician within your system.

Right. So here there's a couple of thoughts to that and that is, uh, our philosophy at this point is that the E H R is a fine transactional system for compliance and regulatory, getting the bills out and that kind of thing. But is the E H R gonna provide the level of innovation that we need to solve the problem you just mentioned?

Probably not. So what have we started to do? We started to create apps. Some are patient facing. Some are provider facing, but example turns out that we have 3000 doctors, and you may know that I am the internationally recognized specialist on mushroom poisoning for every patient in the United States.

Bizarre as that sounds. I do 900 consultations a year. Wow.

At per we in our app identify among our 3000 doctors. Sure there's an orthopedist, but who's the guy who's the specialist on the right shoulder? You know, who is the person who knows more about mushrooms, whatever. So you go to the app and say, this is the nature of my sign or symptom. And it's not a Google search, it is actually a curated, metadata driven way of directing you to the right care.

So again, everyone can practice at the top of their license. So we've written that. Yeah, it's interesting. I, I would just like to get, and, and I, I realize that that's an app. Way of doing it, but you know, you have this health domain. It would be great if that becomes the curated, uh, you know, content where I can go and do a search and I don't have to worry about how good is this content, is it directing me in the right direction?

How do we get that into more people's hands? Actually, I, we could probably talk about this a while. I think it's a fascinating problem. If people are going to Google, how do we, if they're going to Google or, or binging or whatever, they're going to. How do we, um, how do we leverage that to better health across the board?

And I understand that the homeless person isn't going to Google, and there's other things around social determinants. I don't wanna get mail from people around this. I, I get it that it's social determinants is bigger than this. Um, but there is a significant portion of people that they're, the first thing they talk turn to is the internet.

And I think that's what domain was. Sort of geared towards is much higher quality data. Is that, is that your understanding as well? Yeah, it's early though. Very early. And so what are we doing, to your point? I think it's in, it is our responsibility to actually create Alexa apps so that you could be in your home and say, my father is speaking in word salad.

What do I do? And so at the moment, we've created 30 different Alexa skills. And, uh, everything from care planning, helping you understand when to take your medications, scheduling appointments, and those sorts of things. So I'm, I'm hopeful that where we can get to is a point where it's ambient listening in your home, supported by cloud hosted decision support services, um, and it, it gets as easy as, you know.

Alexa, ask B I D M C. , and then you get, because we've registered the keyword, B I D M C, the curated suggestion as how to navigate from there. Exactly. Well, great. Uh, all right, so we're gonna, uh, move into our next section, which is, uh, the soundbite section here. I just, I toss out, uh, five questions and you're gonna give, you know, one to three minute answers.

If you go over, there's no buzzer, there's no whatever. You know, we'll just, we'll, it's more of a, a guideline than a we'll down. So, um, so I'm traveling, this is my East coast, if you will. Um, And, uh, hitting some clients this week and next week. Uh, and I was in the room this week with, uh, two senior leaders, uh, on a healthcare IT team that came in from outside of healthcare.

And it was fascinating, you know, very talented people from banking, from uh, manufacturing. It's interesting where these people are coming from and they're being brought in because of their specific technology skills and, and, uh, you know, new models that they're looking at and those kind of things. Um, do you think this is a trend that's going to continue?

And what, what do you think the hardest thing for these people to really grasp about healthcare and the transition to healthcare, uh, is going to be when they come in from the outside? Sure. So I guess two thoughts to that is that if I were to ask where do I want to partner with innovators? Is it retail?

Is it banking and finance? The answer is, it's actually consumer. So look at what Google and Amazon and Apple and these sorts of folks are doing. They're creating tools and technologies that at very large scale can empower a lot of interesting innovation. The challenge is, is those organizations don't have the healthcare domain expertise precisely.

And so if they offer a cloud hosted machine learning service, it's now my responsibility to make sure that it has the appropriate domain knowledge integrated into it when I create an application. So that's okay. You know, consumer companies go create the generic and then I will go create the vertical using that tool.

Interesting. And that's what they're looking for when they partner with the health system. They're looking for that deep, uh, domain knowledge. They, uh, and they recognize, I think now more than ever, when you talk to a Silicon Valley startup, uh, or even one of these bigger players, they will say, we need strong, uh, health system partners, uh, partner with physicians and, and have those conversations.

They're, yeah. Um, great. So, uh, second question. This is more broader. So healthcare analytics, getting a lot of. A lot of conversations around this and, you know, 'cause it, it can veer off at this point, at this juncture in our history. It can veer off in a lot of different directions. It's still predictive versus, uh, you know, retrospective and those kind of things.

But predictive's getting more interesting and you're looking at machine learning. You're looking at AI and some other things. Um, so this might be another question that you answer with governance, but how have you structured your healthcare analytics? Practice, um, to optimize it for success and, and the, the changes that are likely to come here in the near future.

Right. Well, of course, as you point out, it's all requirements driven, which is in order to be successful running an a c o, you need a set of benchmarking reports that are retrospective, that are looking at quality and cost and variation across.

Providers. However, what's the trend is moving away from business intelligence and to machine learning. And as you suggest, I am going to take a patient today and based on machine learning techniques of 2 million patients before them suggest what their right course of treatment should be and start to schedule the interventions I'm going to make.

You have to pick your use cases a little carefully there, right? This is not, we're replacing doctors with machine learning. That's not it, but it's saying, aha, you need a a surgery today. Actually look at 2 million patients like you, and here's who should do it, how it should be done, and how long it will take.

That's the kind of interesting, not so much business intelligence 'cause it's more complicated than I have to look at your age and your ethnicity and your comorbidities and model it in a predictive way using a machine learning approach. We've got about a dozen projects that are governance groups have suggested our appropriate use cases for that approach.

So your analytics, your analytics projects are really bubbling up from all over the organization, from a lot of different governance groups. There isn't. Group per se. Well, so in a $5.5 billion organization, you can imagine that you have a lot of stakeholders. So sometimes the stakeholders are the accountable care organization.

That's one set of analytics. Sometimes it's the quality folks, sometimes it's the compliance folks. So sure, all this ultimately bubbles into governance. But I believe in a, you know, very federated approach, which is that I'll delegate to the A C O what analytics they need. I mean, I can't decide on their behalf and hopefully I've built this generic infrastructure of normalized data.

It's accessible via a variety of tools and a new machine learning capabilities that address these various stakeholder needs. Yeah, it's, it's interesting, and I, I, I think you probably know this, but there's so many different models out there around, uh, analytics and how it bubbles up and how it's governed and where data governance resides.

And, uh, it's, it's really, it's one of those areas that's fascinating to me, and I, I, I'm gonna keep diving into it on this show and, and see if I can. Unearth the different models that are out there. Uh, third question, and this gets a little geeky, a little more technical, but where have you seen Agile and Scrum done effectively in health?

It, so a challenge, of course, is that, um, given every project that comes across the transom in it, you got two or 300 different threads at any one time. It is really hard to do innovation when you've got two or 300 projects that are just keeping the lights on . So where we've started to use this sort of more agile approach is, I'm gonna call it almost analogous to, you know, the Google 20% work on something different than your job.

Approach. So we've created a meritocracy where if you have proven yourself to be particularly skilled and resilient, we are going to give you the capacity to spend some amount of your time every week on a radical new breakthrough using an agile methodology with a notion that we'll do it fast and we'll fail fast.

When I see people doing innovation centers as skunk works, just separate from operations, doesn't work so well because you can't get adoption. When I take people on the inside of the operation, carve out some protected time, give them an agile methodology and have them move really fast, try things and fail.

At least for us, that's work. Yeah, that's awesome. Um, fourth thing, uh, what are, what are the qualities of a great c t o? So chief Technology Officer, uh, within healthcare, do you think? What are you looking for? Yeah, so here's an interesting challenge. So I'm 56, young, young , but what was the technology that I grew up with?

Well, you're a journalist. It was called Smith Corona. Yeah. And I actually know what a carriage return is, dinging , right? And so my problem is as a 56 year old, I am biased. By 50 years of experience of technology that I had to build and sweat, and it was all hard. And so what I want a c t O to be is somebody who has more neuroplasticity than me when, when somebody approaches them and says, oh, there's this great way you can use Twitter.

You know, I, I might roll my eyes because I.

Twitter isn't necessarily the native technology I speak, but A C T O should say, well, I can actually, I can look at that objectively. And so it's that I don't come with not invented HEAR syndrome. I don't come with too many biases. I'm willing to be a very objective evaluator of whatever comes across.

Yeah. So how many I B M electrics do you still have in your health system? Um, that I think there, I, you know, I can't count, but certainly would be on the hundreds. Wow. It's, that's ama Yeah. That's amazing. Uh, but, but why Right. Forms try filling out a government form on a, on a printer. Yeah. You have to find one of those old Okie data.

Matrix, um, yeah, with the special forms. Uh, and quite frankly, a electric is just easier, uh, for some people to use. Um, so la last question here. So, uh, you maintain, uh, as people can tell, you maintain extremely positive attitude. Uh, I'm sure you've had many difficult meetings, uh, as many as the, the next C I O.

Uh, how do you keep from becoming cynical? How do you keep that, that positive, uh, frame of, frame of mind? So what's really important for an IT leader is to have something in your life that grounds you, right? So if I got customer emails this afternoon that said, I hate you, you're horrible. I go out and hug the llamas, right?

So remember, I run a 70 acre organic farm that is a, the animal rescue for the entire Boston region. And so I have horses and cows and pigs and I'm up at 4:00 AM shoveling manure, and if I have a bad day, I'm just out in the barn. Something that you can look to that is some part of a greater good keeps you grounded.

Yeah. And the, uh, the animals aren't tweeting out, uh, negative comments about you these days, I assume, although some they're writing anonymous editorials in the New York Times, though. It's a, you know, those llamas, you gotta watch 'em . Yeah, they're, they're crafty sitting over there, uh, with those neural implants connected to the internet.

Anyway, . Hey John. Thanks. It's always awesome to have you on the show. Um, what's the best way for, uh, for people to follow you? Sure. So of course, you know I blog though I'm doing a little less blogging these days because the attention span in general in the world is less. So Twitter at j Halamka and I'm also on Facebook and of course you can find out what's going on on the farm by

Unity forum Uh, great, fantastic. You, uh, you can follow me at the Patient cio. You can follow the show at, uh, this week in h i t on Twitter as well. Uh, website this week in health Catch all the videos on the YouTube channel, which we talked about earlier. And, uh, and we will be, uh, cutting this show down into three minute segments for our attention span.

Uh, and actually it's, it's not a, it's not a joke. There's so much going on in it. You just have to make it, uh, consumable for people. And so that's what we're doing here. Uh, so thanks again, John. Please, uh, you know, for our guests, please come back every Friday for our news information and commentary from industry influencers.

That's all for now. Thank you.

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