March 17, 2023: Between financial pressures and the worker shortage, healthcare is under siege. There are many options for prioritizing in 2023. CIOs Brad Reimer (Sanford Health), Aaron Miri (Baptist Health), and Craig Richardville (Intermountain Healthcare) share their perspective in the realm of tech debt, how to get in front of CIOs, and interoperability. What does digital front door mean? How can vendors get in front of CIOs? What are the top clinical initiatives that are driving healthcare forward? How can you prioritize the patient experience while making sound business and financial decisions?
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Today on This Week Health.
(Intro) 📍 keeping the patient at the center of those decisions rather than being more of a business decision is really refreshing. It's really good when you can get two mission based organizations to come together and say, with the patient at the center, how are we gonna make this better as a combined organization? If we can't then that's probably the end of the deal. 📍
Thanks for joining us on this special keynote episode this week health conference show. My name is bill Russell. I'm a former CIO for 16 hospital system and creator of this week health, a set of channels dedicated to keeping health it staff, current and engaged. For five years, we've been making podcasts to amplify great thinking to propel healthcare forward.
Special, thanks to our keynote show sponsors. CDW Rubrik, spectra. Trell X for choosing to invest. In our mission to develop the next generation of health leaders. We have a special episode for you today? We have pulled our January webinar where we talked to three CEOs. About their priorities for 2023, we've gotten so much demand to have this out there for people to listen to that we decided to put it into a keynote episode for you to hear. And here it is now onto the show.
📍 We're gonna get right into it. If you are following me on LinkedIn, you know that I do a LinkedIn poll every Monday. And one of the polls I did, and this will kick us off is what is gonna drive healthcare's priorities this year in 2023. With LinkedIn, you can only really give four choices and then people have to choose one.
The first one was financial pressure, second was disruption, third was patient experience. Fourth was worker shortage and the worker experience. And 86% of the respondents have selected number one, financial pressure or number four worker shortage and worker experience. Some people ask me why I didn't put security in there.
And I think that's just table stakes now. It's not something we think about. So we'll start with this to just get the conversation started, does that resonate with you? Financial pressure, worker shortage? Are there some other things? Aaron, we'll start with you.
Yeah, so I was put like e all the above. So it's all of those and then some, and I think there is a uniqueness bill depending on each of our markets, right? So, I'm sure Craig and Brad can resemble this. For instance, this Florida's a growth market, so keeping up with growth and demand, we're exceeding capacity.
When I look at our capacity reports we're at near a hundred percent at each of our hospitals and we're numerous IDN from children's to adult hospitals. They're almost at a hundred percent with a lot of holding patients. So demand is through the roof right now for medical services, and if you're understaffed and your systems aren't optimized enough to be able to handle that,
you're pushing your assistance to the limit. So healthcare right now is under siege. While we are simultaneously dealing with all the different issues, financial pressures, headwinds, payer, issues there, all sorts of things, and having to combat that while dealing with tremendous need out of the community.
Yeah. Brad, talking about different markets, you probably covered 10 times the geography in terms of just square miles than what Aaron's talking about. Do those things resonate with you, those challenges and are there some additional ones for Sanford?
We definitely see the same pressures that everybody else in the industry is.
And it all comes down to, where are you gonna invest those capital dollars? Is it into growth? Is it into digital transformation? Is it into, the future of data. And I think what everybody is coming to more acknowledgement of is that the staffing shortages and the margin pressures aren't short term gaps that we're just gonna be able to fill in a year or two.
They're gonna require some of that transformational change in the way that we've built the underbelly of the tech infrastructure over the last decade. So I do think that those, even though they're not the fun ones to spend time on, they are probably gonna be some of the heavier lifts for us to really look at and say, how are we changing that fundamental base of our infrastructure and our processes so we can spend the capital and the margin that we want to on those things in a more transformational and being able to accommodate growth like Aaron speaks to.
Yeah. And Craig, to get you kicked off, I've heard Bert present at Bert, your either CFO or former CFO I'm not sure which, at the JP Morgan conference and your balance sheet was always the envy of the industry. Does the financial pressure not as strong at Intermountain?
Are you guys more strategically focused because of that?
Well, we are actually being impacted just like the rest of the industry. We're just a little bit more fortunate that we're on the top, still in terms of our financial performance. But it's much less than what's been optimal or expected.
So the financial piece for us, and I think the labor is a component of the financial piece is the largest expense that we have that continues to grow. We're doing a lot of different initiatives to challenge that labor piece to, creating the digital workforce and doing some extra incentives to retain people.
But, the volume is not a problem. I don't think it's a volume for the industry, it's just that we don't have, like many other industries, the ability to raise our price. And so expense management and the financial is really the biggest piece for us. I think we all experience it personally with going to a grocery store or a gas pump or whatever.
Those prices can vary. Our prices are pretty static, so it is the expense piece, the whole financial piece to get us back to where we used to be.
Yeah, I think people think that hey, healthcare prices go up. We just raise our rates and there's an awful lot of our stuff that's. Right. I mean, Medicare, medicaid bundles, whatnot.
There's a bunch of stuff that's fixed. In fact, a significant amount of it is fixed in terms of reimbursements.
Well, bill, I would just ac challenge that now, you're also seeing payers say if you wanna add into a new service line or add a new hospital, you have to take a 30% reduction across the board.
So there's a major issue right now when it comes to payment and payment reform side of things. That has to be addressed. That is a major problem.
Yeah. So the questions are interesting, and normally I would have my 15 questions and start going down the thing, but since we have so many from the field I'm looking at this going let's see.
So they fall into a couple categories. One is, what are some things you're prioritizing for this year? Let's start there because people are asking how are you prioritizing, what are you prioritizing? Those kinds of things. So, Aaron, we'll come back to you. What are the kinds of things that you're prioritizing this year from a budget standpoint and maybe the corollary.
What are some things that you're letting sort of, maybe not fall off? Cuz projects never go away in healthcare. They just sort of sit on a shelf if we're not working.
Yeah, so we just got through a massive electronic health record implementation. That was a massive endeavor for the health system.
We are now kicking off a back office, ERP consolidation and uplift. So you're gonna see a tremendous amount of consolidation there. That's another big number project that's coming down the pipe. That's driven. I think, Health systems see the return on investment for those dollars spent pretty quickly.
Both from a quality and quantitative perspective, as well as just ease of being able to manage something this large. So that's number one, right? Continued consolidation of our tech stacks, our application stacks, and making sure that we simplify the equation as much as possible too. Automation, making sure that we automate as many tasks as possible.
In fact, the conversation, Brad and I, and another colleague in the industry we were having last night is around exactly that. What are the right tech stack? You'd be amazed at how much hope is sold with not a lot of merit. So we're always asking, show us the real deal. Don't sell us
a promise and hopes and dreams. So Automation three is making sure that we continue to invest in our staff, our existing teams, making sure they have certifications, making sure that they're paid fair market value. I do not want to see our staff leave for the Amazons or others, which, by the way, Amazon's cutting 18,000 people.
So if you want to go, you are gonna deal with that. Those are the kinds of things that we have to continue to invest in, which is concealed consolidation, automation, and that I will not also leave out though analytics with automation, right? Making sure we can actually see the lenses there, and then of course our people.
Those are critical components for us as we go forward.
Great. And Brad, I won't do this to you too many more times. I'll let you go before Aaron next time. But cuz I assume some of those are the same for you. That's true.
Yeah, if you kind of think about that run, grow, transform model, the run space, the staffing, resourcing, how we're gonna prioritize those, how we're really going to invest into our staff.
We've made a concerted effort on something we've called reverse rounding, trying to get our tech folks better ingrained and tied to the mission of healthcare. So we have monthly sessions to all of our staff are in a required session and we bring in an ER nurse or a lab tech or a rad tech and happens to talk about their day in the life of and where that intersects with technology.
And it's been really positive. And we're just trying to make sure that there's a connection for those that want more of that meaning and the mission and their work. And we do think that has a good impact on attrition. From the growth space, we're in the midst of evaluating some different merchant acquisition activity as well as expansion of our virtual care.
So we're really fortunate to get a philanthropic gift of 350 million to really push virtual care deeper into rural health and bridging some of that access to buy, so that growth, it's maybe a little bit different than the growth that Aaron is experiencing, but it's something that we're definitely pushing into. From a transformation standpoint,
automation is key. Completely agree with what Aaron was talking about there. whether it's clinical or it's on the infrastructure side, we're probably a little bit behind in and to be honest with you, and we need to build up that skillset, build up that talent, and just the mindset of automate first rather than building and designing something to automate later.
And then digital priority is trying to figure out where that does fit in the mix. I think the industry as a whole is trying to figure out what does patient experience mean? What does digital front door mean? And really figuring out where those key investments are gonna be to make the difference.
So we're maybe pausing a little bit to make sure that we've got our priorities straight in that space before we're dumping a bunch of priorities in there. But second half of the year, we'll definitely see that pickup quite a bit, I would say.
It's interesting the automation journey doesn't start with a tool,
it starts with the people. No reason to buy a car for somebody who's 12 years old, right? You've gotta teach them how to drive. You have to, those kinds of things. So if you don't have the skill sets internally on these new automation tools, I think. Sometimes when vendors are listening to this, they're like, why don't they just buy my tool and put it in?
They can do automation. It's like, time out. Somebody's gonna have to put it in, somebody's gonna have to understand it. Somebody's gonna have to program it, somebody's gonna have to bring the workflows to it and all that. Anyway I'd throw that off as a tangent because I hear that a lot of, why don't they just buy this thing?
Definitely the organization change management aspect of that I think is not given enough. Because the tools are out there, I mean, the technology can be put in place. It's do you have the resources and the mindsets and the strategies and the patience to build some of that and bypassing, some other opportunities in the meantime.
So the discipline and making it a priority is probably a bigger impact than the technology.
Craig, how about you? What are you prioritizing?
Yeah, we already talked a little bit about the financial thesis, so certainly efficiency and some of the things that have been mentioned in terms of how to kind of do more with less than the RPAs and the automation and the digital work.
Those are all things that are really to help us become more efficient. One thing that we do have that several other have as well, but many do not, is we also have a health plan. We have a million member health plan. We're focused on value. That's a big piece of our drive moving forward of how we're looking to transform the industry is truly to put our arms around the value propositions and reduce some of the volumes that many are still paid on in, in a lot of the markets.
And some of our markets are that way as well. But the board this year did something rather unique back in December. Most of our incentives, priorities, goals are. Equally rated. They pulled two things out. They said, the two things we want you to focus on, and they waited them appropriately, was the patient and consumer experience.
They really want to see a big shift in that. They want that to be waited for us. And then also on the caregiver provider, the employee experience. So those are two things that bubble at the top for our board. A year from now we really want to see a difference of how our patients and consumers are experiencing their interactions at
intermountain and also, to help fight some of the labor shortage and the burnout and some of the transitions that we've all talked about is really making this the best place to work. What can we do for our caregivers? We're all called caregivers at Intermountain, so. We don't use employee or associate or provider.
Everybody is a caregiver. And what can we do to improve that experience? So there's a lot of discussion about some of the things that we're looking to explore this year to help retain and recruit the best in the country.
Quick answer from the three of you. When was your 2023 budget solidified?
What was the date that you knew what your 2023 budget was?
We use a rolling forecast. Okay, so we moved away from budget, so we have a rolling forecast. So ours is actually very agile,
okay? So it can go up and down based on need. What about you Aaron?
Had line cited in June, board approved it September, October one was our fiscal, so I had a basically good idea by June, July timeframe what my budget was gonna.
Yeah. And how about you,
Brad? Yeah, our process order to errands, we're just a quarter delayed on that, so I probably had good clarity into a September, October and then board approval I, November, December.
Yeah, I think people are like, Hey, how do I get visibility?
How do I sell into your organization. Actually, the question was in here, like two or three times. I think what people don't recognize, except in Craig's case we were talking about what we were gonna buy nine months ago for the coming year. I think that sometimes surprises people.
It's like, well, why can't you pull the trigger? Well, it's like we are gonna pull the trigger. In nine months for this.
Yeah, bill, let me say something cuz I've been on the provider, I mean, the vendor side, right? So I broke away from being a provider in 2015 and joined a large cybersecurity company outta Boston.
And it helped build product and work with them. So I got visibility to this. So for all you sales folks, your sales cycles into healthcare 15, 18 months. Someone's not gonna go from a stage one to stage seven overnight, just not gonna happen. It doesn't happen like that. So patience as needed, which a lot of startups and startup vendors and founders don't understand.
And so if you wanna get in front of us, you've gotta get in front of me, Brad and Craig, at least 15 months, 18 months ahead of time, and begin to sell us with what we actually will need at the time so we can bake you into our budget forecast. So this is a pro. Elongate your sales cycles.
Some questions on cloud DevOps.
I'm merging questions here. So if people are wondering I, is cloud a part of your strategy? Is it a part of your cost reduction strategy? Is DevOps a part of your strategy? Brad I promised not to start with Aaron, so I'll start with you on this one.
I wouldn't say that it's a central part of this strategy in terms of it driving.
Different things in our priorities. I would say we're looking at it a little bit more as an opportunistic, as we find the priorities within the organization that are driven from our clinical and business operations. We will look to cloud options and make sure that it's the right decision for the organization.
We're definitely past the part to where we're scared of cloud. And we think that it's becoming more and more of a commodity I would say and interchangeable with the way we think about what our current technology footprint is and what's gonna match best in that, and how do we see that transforming, over the next couple years.
The one caveat to that is, I would say in our data space, we're definitely pushing much more heavily into the cloud and DevOps space and building that for. I'll just say modern platform. I think everybody in healthcare, we still are a little subject to the legacy on Preem footprint from EHR vendors and those types of things, which it seems to be shifting slowly.
We definitely are getting more, I would say, aggressive proposals from at least the big three cloud providers. The hyperscalers that they say that they wanna partner in healthcare. And I think we're seeing that definitely in sales cycles, how that plays out in terms of what does a true partnership look like, how do they become more mission based rather than bottom line based in really trying to partner with a company rather than just being.
A logo that they can put on their sales deck. So we're really trying to push it into, okay, this gotta be meaningful for us. It's gotta be a change agent for us and it's gotta be something at the end of the day, we can say, this is why it's better for our patients. Before we're just gonna jump for the sake of jumping.
Craig, I'm gonna come to you cuz you're one of the CIOs that has pushed my thinking on this over the years. I just wanna be clear, not that cloud is driving the health system's strategy, but cloud and DevOps as a part of an IT strategy.
Yeah. What I like to say with Cloud now is years ago I think it was a strategy.
I think it had some ways to differentiate yourself from others. And by having that kind of more advanced and progressive technology today, I think it's just more of a tactic. It's not a strategy. Most of us, I can't remember, maybe Brad and Aaron can, but I go back. Five, six. I can't remember when I'd ever purchased an on-prem application anymore.
They just all cloud-based, cloud surfaced have some of the same struggles as Brad with. , some of the historic stuff that we're gonna be migrating and moving out, but those happen when the financials work out to happen that way. So I don't see it as a strategy anymore. I think it used to be just like mobility's not really a strategy.
It's kind of a given. They're table stakes. Those are things that you do that are just part of your portfolio and the services that you deliver. I do think some of the DevOps, that stuff that we're doing and others are doing are starting. , to move yourself a little bit more into a piece that can differentiate you from others.
The comments that was sent out had to talk about, how, some of the core systems that we have. And there is a part of me that certainly believes that we're all driving pretty much the same vehicle. It's just who's gonna be the better driver? It's kinda like a NASCAR race or you can pick what other thing that you want, but we all are driving pretty much the same vehicle, but who can drive it better than others?.
And I do believe that, probably the last thing I'll say on this topic we shouldn't really compete on data. That whole thing about interoperability. We should all have the same data about every patient, every provider, every consumer. It's just what you do with the data should really make yourself different than others.
And but we shouldn't, kind of hold or anything of that nature with that data that should be really free flowing. It has not happened yet. I think you see it more certain. Financial services a little more progressive, but the data they're sharing is really small and the data we wanna share is certainly quite large.
So there's differences, between those two industries. But that openness to having access to that information, I think is something that we all expect as patients and consumers that will, I walk into, one of Aaron shops or one of Brad's shops As a patient, I would hope that provider has everything that he or she needs about me coming in.
And I think that's something that as an industry, we've got to continue to accelerate.
Yep. And I think once we adopt patient-centric interoperability we will get there. But that's another webinar. 📍 📍
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📍 aaron, I wanted to give you the chance to talk about DevOps a. Yeah.
So first let me just throw a caveat out and add on to what Craig was saying about data and cloud.
So for the vendors out there, do not think you're gonna come into a health system, guzzle up our data and then go resell it on the back end. Right? That is creepy. That is happening way too much and it's gotta stop. So Craig is absolutely right. We wanna share data responsibly. Right. So be responsible partners with us and we'll be responsible partners with you.
All right, so let's, wanted to put that cap on that. Regarding DevOps, it's a tremendous focus point for us. We are doubling down an automation of infrastructure level leveraging Ansible and other technologies. I have an entire DevOps team that also builds low-code applications. We have a couple of low-code platforms deployed to the organization.
We're also teaching clinicians how to write their own low-code apps. I don't want to be in business of writing their apps. They should be writing their own apps for them. We already have five apps successfully deployed that the nurses have written themselves. They asked for this, we taught them, they built it themselves.
We sort of sherpa them and helped them. But it's all curated, it's all HIPAA protected and it's very successful. So that's DevOps the other side of this, which we should talk more about is site reliability engineering, SRE. We have to get to certain observability levels so that we're actually watching apps real time, those API connections, and we know what's happening where it's happening.
We've set up an SRE team. We're in the process of making sure that every one of those APIs is monitored appropriately and responsibly, and that way we can restart transactions as they fail or hold vendors to account where necessary. You'd be amazed at how much surprise there is when you go to a normal common vendor and say, I need API access to figure out what your simple uptime is or what your latency is, and they look at you like you have three heads on or something because they're not used to being challenged by the healthcare provider community.
Guess what? We are acting more and more like the Netflix and Facebooks of the world, so you have to play ball with us and have that level of granular resolution.
Wow. There are some questions on interoperability and integration. I'm not gonna have all three of you answer all these questions.
I'm gonna throw out a question and if you have a strong answer, I'd love to hear it. Can competing health systems see benefits to promoting communitywide interoperability. And Craig, I'll come back to you since you brought it up. I did a podcast with Intermountain and I love the stuff.
Not only they're doing in terms of data sharing, but also data sharing across the social determinants with the United Way with others was really impressive. So, I'll just go back to the question. Can competing health systems see benefits to promoting community-wide interoperability?
Yeah. I think if you always ask yourself the question, what's best for the patient?
If you always put the patient first, that answer to that question becomes easy. We should not compete, again, about the data and what we have about that patient. The best interest of the patient is to have that data be free-flowing in a nice, secure environment as Aaron put around it. But that has to be there, and I think the competion
for us and for hopefully many others in the industry is really to make sure that we don't compete on that data. The interoperability is part of the organ the foundational structure of how we operate within our industry and that we compete on other things outside of that, the experience.
Promotion all the different pieces that we're talking about before. I really think that competing health systems should promote and push interoperabilities. They compete on the right stuff and that right stuff is not about the data Interoperability, it should be a foundational element of our work.
When you look at the things about the social determinants of health and things of that nature, and things that we know that are certain characteristics about our patients or our consumers or our future patient. those things again, should be free flowing and available so that if you are the patient, no matter which organization you go to, that patient, that organization has the most amount of data that he or she needs to better take care of you.
I think many of us know that, the medical pieces that we're focusing on, is maybe 30 or 35% of what you need to properly treat a person. And the rest of the information, again, should be a available and share d that we do compete on things that are much different than what today some people would say they're competing on.
Yeah. And just so people know, this is not only a cio decision on how data is shared and whatnot. There's an awful lot of people involved, but the next time I have you and Donna in a room, I'm gonna hold you too accountable. To seeing how much data is flowing between your two health systems, by the way.
Yeah, we have a big children's hospital sitting on her campus, so Absolutely.
At this one I will have all three of you answer top clinical initiatives that are driving technology. Or just top clinical initiatives. Now, again, I wouldn't go into, I mean obviously there's a lot of 'em go into like one or two that are interesting, that are technology related.
Aaron, we'll start with you. Clinical initiatives.
Yeah. So we're expanding our hospital at home programs. We had a very successful foray, especially during covid 19 with covid, long covid morphed to C O P D. And a few other common conditions we're expanding that cause the demand in the Jacksonville and southern Georgia regions are for that.
That's one. The second one's around pediatric, particularly around mental health and mental wellbeing. So what you're seeing is a lot more care extended into the rural communities and into the home. Well, that changes the game because do I suddenly become like Best Buy Geek Squads supporting gear in someone's home?
How does that work? What's that response look like? So it's almost like home health. For it in someone else's house. So how do you provide them cellular connectivity, other things so you have a certain baseline for connectivity and raise a level of standard. The more acute the condition, the more real time that data has to be coming back into your systems.
So we're in the process of working through all of that and stepping through that because it's a very successful business model for us and the demand is here in the community for it.
Fantastic. Brad. Clinical initiatives driving technology?
Yeah, I saw, wait, one of the questions that we kind of talked about in the prep a little bit was enterprise imaging.
So we went through an enterprise imaging centralization a couple years ago. and we continue just to build on that and iterate on that. And it's one of the things that our caregivers and clinicians are actually using and promoting, or they're trying to attract other caregivers into the organization just because of some of the cross integration that is bringing us by having everything on a common platform.
So that's one we continue to iterate on. I think, as everybody is, they're focusing on some, they're maybe not, Clinical advancements, but they are things to remove the burden from the caregivers. So, whether it's, more self-service tools or if it's leveraging some of the computer vision type tools that can augment some of the workforce in a different way from different locations through different virtual tools and automated alerting and those types of things.
Those seems to be the ones that are getting the majority of the attention right now just because. We know that burden is something that is real and something that we need to address to allow them to operate a top of their license.
Greg, I'm gonna come to you in a minute. So enterprise imaging is interesting to me.
Are you saying you've got to a single imaging system across radiology, cardiology, all the various. aspects.
Yep. Wow. Yeah, that's been a pretty major initiative and implementation over the last few years and just got some of the cardiology stuff on here within the last year that really has brought that together.
Yeah. That's fantastic. Do you guys have that same benefit at Baptist and Intermountain? Have you gotten to a single imaging
Well, we have gotten to two imaging platforms that have a pediatric and adult side, right? So right that's down from like seven. So I feel that's success. But we're trying to consolidate to one.
We do have a vendor neutral archive so that we have a universal viewer. So you can see from both, but there's some very specific instrumentation that goes between pediatric and adult that's very specific to those worlds. So we're still working through that with those vendors to say, can one of you build a comparable model so that we're good and go to one?
So it's all about the medical instrumentation. ,
and if you can get down to that one, I would imagine overlaying those AI machine learning models on top of that would become, easier.
Well, I'll give you an example. I've got over 2 billion stored PAX images that are sitting resident. I would love to assess those for some sort of, AI radiology study or, trying to spot the tumor beforehand.
But how do I do that when some of them have your own proprietary dcom wrap or other things that you have to unpack, right? There's a lot of nuance to a lot of these vendors and how they've given you your data sets.
Yeah, absolutely. Craig clinical projects.
Yeah, there's there, there's a ton to choose from.
Just last week Gartner announced we won their innovation award for our 3D printing that we're doing in our surgical areas. And very proud of that team. But the one that I would highlight that I think would be more applicable to the audience would be the ambient intelligence that we started several years ago.
One of the first ones with nuance. To start with them, kind of part of their beta program and their early adopter program. And that has continued to be a tool that has been great for our providers and for our patients. So we've said great benefit from that, is using the. and, artificial or advanced intelligence and machine learning that's providing time back to our providers is providing a more accurate description of the visit that took place.
It's a more accurate coding that takes place and the patient, is in a more advanced setting, kind of making that happen. just having a normal dialogue and conversation with the provider with little to access to a computer by the provider during that visit. So it's kind of going back to where that personalization has taken place for us historically, that in some cases technology kind of broke that away but also then providing a better outcome and the back end for both the documentation of the visit as well as financially of what took place during that visit.
So I'm a big fan of that. It's not for everybody, there's a certain segment of our providers that are already very advanced in how they're using the electronic tool. There's others that you don't want to make that transition or that change, but it's continuing to spread that people are seeing others, talking about some extra time, that they're having extra patience, they're able to serve and all those things, those economies are coming from, that tools.
So that's the one that I think the other people should look into if they haven't already.
Absolutely. So, one of the questions we have here I think the answer is governance, but how do your organizations rationalize competing priorities and adjust as business needs change? So that's very high level to say governance.
Craig, I'm gonna come to you cuz you have a different budget model, so you, yeah. It would seem like you guys have a constant flow I remember our budgeting cycle, all these projects, and we were evaluating 'em. It would seem to me like you're doing that all the time.
Yeah, budget is a word that you get corrected in every meeting.
If you use the word budget. Budget is no longer a term that we use at Intermountain. It's all about forecasting and the way that we are doing it today. And actually just started. We're nine months into our merger these two organizations. We have other m and a work that we're still cleaning up historically and also looking at moving forward.
but we've changed it rather dramatically. So, neither organization had the proper one for what would set us up for the future. So my governance is five people. That's it. It's myself and then I've got the chief operating officer. I have the chief clinician the chief financial Officer and Chief Strategy Officer, and we have other subcommittees and work that's happening up underneath that are all co-led within dts.
So we're called Digital Technology Services as well as somebody from the clinical or from the business side. All that work happens up underneath. Then it comes up to us four to be able to. Prioritize that work and say yay or nay. Right now, I would say on the financial side, we're looking at things that have returns of 12 months or less.
So no longer is the five year r o ROI or a three year r o ROI if they can't pay for itself within the year, given the dynamics of what's happening within our industry. And the impacts that are coming in, we don't know, in three years, odds are things gonna be much different than what they are today. So the assumptions you're building into a longer term return are really invalid in today's world.
So we're looking at very fast types of implementations of returns on those investments. And that group of five, the four that serve with me that's what we're focused. ,
so ROI 12 months. I'd like to hit the other two gentlemen. ROI these days that you're looking. Aaron, outside of the E H R and the e r p what are the typical ROIs you're looking at?
Yeah. 12, 15 months usually is a no-brainer. 24 months up, 24 months, you're pretty much gonna get, okay, good to go beyond two years roi, or at least breakeven. You really have to prove the point. Are you doing something else to help, bring in top line. Better ebitda, more efficiency, what is it?
And really work through that and then prioritize effectively. I will say a shortcut I have found even with elongated return on investment calculations of performers, is tying it back to service line growth and how that will help grow as a knock-on effect your service lines. So have the business discussion first, then have that tech discussion if it's beyond 24 months.
Yeah. Brad, do you guys have an roi you're looking at?
So the things that are getting prioritized and getting the attention are 12 months . or. There's enough of those that it's really kind of forcing us to think about things in much more of an iterative and agile manner to where we're looking for smaller, quicker, earlier wins.
And then grow on that over time, rather than wait for a 12 to 24 month initiative that has even a longer tail on. On what the return is. So I definitely see the tide shifting. We're still kinda locked into our annual budgeting cycle but that seems to be more focused on what your base operations and run the business type expenses are.
And we're looking at the grow and transform in more of a, quarter by quarter. Hey, let's look at the results. Let's see what's happened from cash and capital. And then we look at what we can invest forward. And right now the ones that are getting invested forward on those ones that have the quicker returns.
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All right. Last technology question, then I'm gonna go to people questions. Tech debt. So, I know it's a bad word and it makes you shiver when you hear it, but we all have tech debt. In a financially challenging time? How are you making sure that you're not accumulating even more tech debt?
Because we all have an acceptable level of tech debt and then we have a dangerous level of tech debt. It seems to me those are the two things. The gauge goes from green to red. It doesn't go. Yellow Aaron I'll throw this one at you. Tech debt, how are you making sure that it doesn't grow?
Well, first it starts with what's your mantra, right? Are you cloud first? Like we're all saying here, and there's still some shops that are very much on-prem first. So if you're on-prem first, You're already assuming a level of technical debt that you're acceptable with, right? So that's number one.
What is your mantra for us? I threw a gauntlet out there. I said I want no data centers at all, anywhere in three years or less. And we are marching to that, right? We're gonna be 100% cloud with some local survivability because we do live in hurricane Alley. So I have to think that way. , but regardless of the fact, we'll be mostly cloud, multi-cloud at that.
That's number one. Number two, do you know your landscape? Have you actually done an inventory and you can visualize it? I actually had it printed out on this giant piece of paper stretched end to end the size of a football field. Our entire technical stack from application layer all the way to database layer and put it in front of our board of directors who said, guess what?
You have about a dozen of everything. I'm gonna consolidate this. It's gonna create some noise, but I'm gonna need your help when those respective folks call you and complain. Cause I'm trying to consolidate our tech stack. It was eye-opening for everybody. Last but not least, make sure you're continually train your staff so they're not married to some tech stack of the old saying, well, all I can do is program on an AS 400.
Well, now you're gonna learn some modern technologies. I know you do an AS 400. Well, we're not staying on an AS 400. We're now going to something new. So if you hit those three dimensions, you should be in a pretty good position.
I like the AS 400. It never went down. It was really reliable. True. That's the problem with it.
Brad, tech debt.
One of the things we've done is really kind of change the dialogue to be more risk and opportunity based rather than talking about it as tech debt. Hey, let's look at these different systems and say, okay, if it is aged, what are the implications of it being aged? And are we okay with that or not?
And what's our plan with it? Rather than just saying, well, we'll figure out a plan. And that plan may be to sunset it, maybe to upgrade it, maybe completely get rid of it just because it's not serving a value anymore. So we've really started to change the dialogue. We've got four major markets and we have those discussions because they're.
Typically have came from previous m and a activity and they've made their tech debt profile may be a little bit different. So we're sitting down with those market leaders and just kind of talking about what are you taking on by holding onto this with us and let's make some joint decisions around it just because it's old.
Unless we start getting into issues with supportability and not able to patch it in, those types of things, those will be brought into. what the risk profile is, and then that's the discussion we're having with those leaders so they can help prioritize where we are putting some of the investment.
I'll tell you what, Craig, these guys are much better CIOs than I was. I had a 24 year old PBX in one of our largest hospitals that we were buying parts off of eBay to keep the thing running. But I'm sure you guys don't have that. Craig any approaches to tech, by the way, I like those two.
But as long as you know why you're keeping something and you're allowing it to age and you have a plan for it it's fine to let certain things age like that. 24 year old pbx, we actually had a story around what we were doing and it was an acceptable story and we knew we could keep it running.
So, Craig, what are your thoughts?
Well, speaking of age Bill, I would say following your career for a long time the older you've gotten, the more actually valuable you've been to the industry. So I think it's, I think ages of, so I'm
not tech, I'm not tech yet. Okay. ,
no, but I would say two words.
I would say simplicity is standardization. I think there's people that have grown up or raised or educated that complexity is, it is like, Hey, let's make it simple. Let's stop making all this complexity that we've built into, not only within the technology area, but also within.
Healthcare delivery or healthcare payer side of things. The simpler that we can make it, I think, the better the outcome's going to be. And then the standardization, just remove all the variability. Now, similar to Brad, we're a big m and a shop, so we're always gonna have that for a period of time, and at the right time then we will continue to standardize.
But that doesn't mean that we standardize on what was the standard yesterday. It may mean that something totally shift. To a whole new different technology because of, the value contribution it's going to have. But we're gonna spread that across all of our regions and all of our markets.
All right, so are all of you thinking about application rationalization? I mean, does that like, just absolutely. Mantra? We're simplifying this environment, we're reducing the number of apps. And I lied a little bit cuz was gonna talk about people next. Next question.
I absolutely will. I wanna talk about m. All of you have mentioned m and A at some. And we've seen m and a strategies where organizations come together and three years later they're finally having the discussion of which er EHR are we gonna go to. But we've seen that really morph over the last, I would say 12 months, 24 months to a playbook.
It's like, Hey, if we merge with an organiz, This is what it will look like within 12 months. Is that a common approach at this point? I'm just gonna throw this out. I don't know who to call on. Is that a common approach now to have a playbook and say, look, if we are gonna do m and a, we know what our approach is to technology.
I'll jump in first and let Brad and Aaron and, kind of, go on top of me. But what I see right now, what we've done and what I think our future is, it's not the rip and replace that you've seen historically. It's just unaffordable and the value that comes out of that.
It's just not, there may be a right time to do some of that work, especially with the larger investments. But it's not just to do it. And so, if you got, depending on what the depreciation cycle is, there's just a lot of factors. And how much change management's already taken place at that organization where they're already part of some m and a recently, and so you're not gonna do it to 'em again.
I don't think that's really the, a practical way of doing it. So for us, it's all kind of gets built into, the agreement that takes place, but it doesn't really have a defined timeline. It has more of a vision of how we're gonna be moving forward and really kind of a roadmap more toward like guidelines and boundaries for us to progress forward with.
So we'll have a unified this or one of these, doesn't mean it has to be a single thing, but we will present it so that it is a unified patient portal, for example, or a unified EMR or revenue cycle or whatever those are.
So a unified experience for the patient for sure, Yeah. And potentially as much as possible for the clinician.
100%. Those are the two things that our board has prioritized for us. And our m and a will support, know, ourselves moving in that direction for those two initiatives. But it's not a timeline that's set up that says you have to rip and replace something, or we have to be on a single something.
It needs to be simpler, easy to use, more intuitive. It doesn't mean it has to be one.
Interesting. Anything you guys would add before I go to the people side of it?
The only quick thing I would more doubling down on what Craig was saying is, you go into a more with what's the benefit for the patient gonna be based on this decision.
And if that's not clear, then you know, you kind of go onto what the next one is. So I've seen at least. A little bit different I'll say in the last decade, to where keeping the patient at the center of those decisions rather than being more of a business decision is really refreshing and it's really good when you can get two mission based organizations to come together and say, okay, with the patient at the center, how are we just gonna make this better?
As a combined organization? If we can't then that's probably the end of the deal.
I would just simply add that electronic medical record is not a strategy. It is not, and I've heard too many times people say, oh, we'll just go put so-and-so EMR vendor in. If you merge and you're good to go wrong, you're gonna fail and fail miserably.
So exactly what Brad and Craig have been talking about, it is about the patient first. Have that discussion with your executive team.
Okay, what's the future of work from home? We saw Elon Musk take a few arrows through the holidays for not only getting rid of half of his staff, but also bringing the other half in, and a number of other myriad of mistakes that he made that they teach us in management school not to do.
But regardless. He's not the only one who's bringing workers back. Goldman Sachs is bringing workers back. I've talked to a healthcare CIO in a major city who's bringing their workers back on specified days, three days a week, but three specific days. Everyone will be here Monday, Wednesday, Friday, so that they get that collaboration.
So we're seeing a little bit in healthcare. We're seeing it happen in banking. A lot in some other industries. So this is probably a closing question and I'd like each of you to talk about how you're thinking about culture, your people, and what the future is.
And if you could throw in stuff about training as well, keeping them updated, that would be good. So it's a broad. Closing question for each of you. Aaron, you started first. I'm gonna let you start first on the last question.
Okay? No problem. All right. So my personal philosophy is if I expect you to work for Baptist, I expect to trust you emphatically where you work.
How you work. I should be able to manage that with smart goals and measure it effectively and know that you're getting a quality job done. Now, I also do believe that you need to come to site from time to time, interact with our caregivers, make sure you're round. There's some IT roles. You just have to be here.
If you're a desktop technician or part of our DSS team until we have robotics, roaming the halls, replacing computers, you're always gonna be, have to be on site. So there's certain roles. You can't really be remote, but let's call it for at least 60% of my staff, which it is today. They work from home or remote, they come in periodically, at least once a month for a couple of days a week.
And they're able to work with folks round, shake hands, be able to build those relationships. Cause healthcare is a relationship driven organization. I will say this, if you are planning to go whole hog on new technologies like site reliability, engineering observability, those people with those skill sets live across the.
I'm not saying you can hire from every state because some states have really funky privacy laws and others, but for the majority of the United States that you wanna hire from, that's where that talent lives, and you have to inspire abroad as well as you inspire locally.
Have you lost anything in going with that approach?
No, I actually haven't. I've actually gained a lot. I've gained a lot of culture, I've gained a lot of trust. I've gained skillsets quickly and I've seen my staff not feel as beat down because they're not driving in their car, stuck in traffic for forever. So from my perspective, . It's been nothing but a net benefit.
I will say it's T B D for healthcare though, because I do see a lot of the dovetails of wanting to be like Goldman Sachs, come back to campus, come back to campus. But I'm blessed with a good executive team here is very forward thinking and progressive. Not every hill system has that, so your mileage may vary.
All right, Brad, we'll let you go next. And Craig, you'll get the last word.
For the most part, I agree with what Aaron's kind of speaking to for a talent pool perspective, especially the upper Midwest. Not being part of a major metro, we've gotta have the flexibility for people to work from every corner of the nation.
So that flexibility is key. There are those roles like Aaron mentioned that those are gonna have to be on site for just local boots on the ground support. . What I've really found interesting and what I'm hoping just continues to happen is inorganic drive for teams to themselves say, I need to come back into the office for days or together.
And what's interesting, like our network team, some of the most introverted group they're coming in on their own because they're realizing how much they've lost in terms of just learning over the. What do I hear from the guy next to me and just being able to quickly turn and have that higher fidelity dialogue, slack and those things can take you a long way, but it is not the same as when you are in person.
And I think our teams themselves are starting to see that. And if that is what drives them back in the office, rather than me or some other leader saying that they have to be on a particular day, I think that'll just end up with a more productive end game. But regardless, we're gonna have people that are in other states.
We're gonna have to figure out how we combine it in with the team so that the team dynamic is something that we're having to spend a little bit more time on. Just being intentional around and how we're building that teamwork and how we're building the water cooler talk and those types of things, those that don't have the flexibility to come in.
All right. Craig, last word on this, but if yours is very similar to theirs talk about how you're going. Keep progressing your team, how you're gonna keep them on the cutting edge.
Yeah. I act a little bit different. So me, we separate between leadership and non-leadership. Leadership is more onsite, non-leadership, not expected.
At all in many cases unless some of the hands-on type work that was described earlier, being in eight states, with three regions and a dozen markets travel is required for a leader to be present and available and visible to a large part of the organization. Most of the organization doesn't have the.
to be remote. They're onsite, they're at clinics, they're in hospitals, they're in other types of centers. And so I think as a leader, you have to take that opportunity to support them by having a very similar type mindset in terms of what you want to grow and how you want to develop and bring staff.
In the last month, I had something like around 20 new caregivers within my division. They came from 11 states and three countries. So there are three countries, us being one, two other countries where I have caregivers that work within my hierarchy that are serving at Intermountain. And that brings a lot of diversity of thought, a lot of diversity in the way that they perceive things.
Also, a lot of diversity in the working hours. So by not having everybody within the mountain time, but people across the country as well as across the globe. allows me to have people at different times of the day and different days of the week that are thinking hard when the rest of us might not be, and vice versa.
So I think that brings a lot of diversity into play. And so the last thing I'll say was I think your question is how do you grow and develop people? I like to say that you're responsible for developing yourself. I will provide you opportunities. , but you have to take the initiative and you have to be really self-serving with that.
You've got to invest yourself. I'm not gonna pull you along. You need to jump in. And those are the people that will continue to flourish with an Intermountain. And for those that don't like that kind of speed and don't like that kind of outcome, that's expected, it's probably not a great place for you to be.
And so over time, we'll continue that with that culture.
Fantastic. Gentlemen, I wanna thank you. Aaron Craig, thank you for spending your time and investing back in the community. It's greatly appreciated. And for everybody who joined us and listened, I appreciate it as well. Look forward to seeing everybody. Thanks, bill. Bye.
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