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Today on This Week Health.

(Intro)   That is the thing that I think about all the time is, what kind of tools can we innovate can we introduce that will provide a more streamlined experience so our clinical staff can, spend more time with patients,

 Thanks for joining us on this keynote episode, a this week health conference show. My name is Bill Russell. I'm a former CIO for a 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 that amplify great thinking to propel healthcare forward. Special thanks to our keynote show. CDW, Rubrik, Sectra and Trellix for choosing to invest in our mission to develop the next generation of health leaders. Now onto our show.

(Main)  All right, , Leadership Series Rural Health Care Challenges and Opportunities. I want to thank the three of you for being a part of this.

The amount of geography your health system covers and your EMR. I just want you to cover those two things. Daryl will start with you. Same order, Daryl. So

We're northern New Hampshire, so the top third of northern New Hampshire.

I don't know the square miles that we cover, but it's definitely the top third of New Hampshire. Patient population is about 32, 000 that we've been covering. And we are currently on Meditech Expanse.

Okay, fantastic. Scott?

Yeah, I don't, I also don't know the exact geographic square footage, but we cover we're called Southern Coos County, but we actually cover most of Coos County.

We have a lot of folks who come down to our facility from various points in the county and beyond. We also cover the county just south of us called Curry County. we Have a fairly large expanse. Our patient population ranges between 12 to 15, 000 a year. We have a large tourist population that comes through during the summer.

And for we are home to a major golf resort called the Band of Dunes Golf Resort, so we get a lot of golfers. But we're also we have a lot of folks coming to do natural outdoor kinds of recreation activities. So we get a lot of folks coming through particularly right now. and our EMR is a CPSI product called Evident.

Wow. Cool. So any specific ICD 10 codes for golf injuries that we should know about? Mostly

ankle injuries.

one of our CIO events, there was a health system CIO there who was a physician who told us. What a ICD 10 code was for a bayonet wound because he was in Gettysburg and Every year during the reenactment at least one person cuts themselves on a bayonet.

So anyway, just that's fantastic Ryan Health? So depending on how you

want to count it, the easiest way, if you take Montana and you cut it pretty much in half, everything east of Billings is where we serve, so that's about 40 to 50, 000 square miles, and then everything north of Casper, Wyoming and Wyoming, where they only have QHC serving all of those communities, grand total at something like 70, 000 square miles that we're the only FQHC serving. Obviously not all those communities we have direct patient care in, but we do have a lot of telehealth encounters that happen from there. And so a fairly big area where I'm located at is in the middle of that in Hardin, Montana.

It's funny you mentioned bayonet wounds because what we're famous for is Custer's Last Stand. And there's a reenactment here every year. So yeah, some interesting wounds that come out of that. Obviously people getting hurt. We had a, one of the riders who got bucked off his horse and got pretty injured from that two years ago.

But we're on Athena Health for a health record.

Interesting. All right. I'm gonna have you guys set this up and what I want to, what I want to do is. I want to understand the distinct challenges that are facing rural health care. And we'll start to rotate who goes first here. And Scott, I'd love to hear from you.

What are some of the distinct challenges? that you're facing as you're trying to care for the vast geography that you're trying to

care for. Thanks, Bill. I appreciate the the opportunity. I've been in my role for about five years. I've been with the facility for nine years and As a CIO, the biggest challenge is from my perspective is, We've had some significant leadership change in our C suite, and particularly at the CEO level, and that has been very challenging to sustain projects over time. And particularly EMR conversion projects. And so I did mention that we are currently with CBSI evident. However, because of our growth goals, we believe that we need to move on to a a new EMR and ERP enterprise resource planning system.

And so we are actually right now in the middle of vetting out a EPIC Community Connect two EPIC Community Connect vendors. but that has really only been possible because we've had a stable CEO position for about a year and a half. And he's come in, really stabilized the hospital, its reputation in the community which was very challenging for us and put some key people in place across the organization that have given us the opportunity to consider long term planning, long term goals one of his first activities was to get us all in the same room along with our board and put together a strategic plan.

And we had to have strategic plans in the past, but they didn't really have any teeth. They basically, I'm sure that others on the call will have had some similar experience in their past. we had a strategic plan but we didn't really follow it. We didn't update it. Our new CEO is really a believer in reviewing it.

Every week we have standing meetings where we're reviewing our strap plan and we report monthly to our board on our progress. A significant part of that strat plan was the EMR conversion. And that has been the second biggest challenge is is the limitations of our current EMR and trying to move to a better solution.

And so now that we've had a stable leadership both in the executive team and also at the board level we are able now to Dig in, look at look at various vendors. We hired an external company to guide us through the vendor selection process. And we're in the midst of that, and we we hope to have a recommendation to the board by our September board meeting.

That's interesting. I'll say what you can't say, which is it's interesting, because you're rural healthcare. You have two, two problems. Either you hire somebody who is not at the top tier of the CEO ranks. Or they would go somewhere else. Or you hire somebody who's really good and a great up and comer, and if they have any ambition whatsoever, they get snatched up the first opportunity that's there.

And that is one of the things is the turnover at those levels creates some instability. It's interesting. And I'm sure we'll talk about staffing and labor as well. Ryan, how about you? For us, the thing that

makes it a unique challenge where we're at is talking to a lot of other people that serve rural communities and even like Billings, which is next door to us, and they try to serve rural communities.

They actually leverage their large population base and then provide services as a spider web out. We don't have any large population bases. Our biggest community that we serve is about 20, 000 people and all the rest of them are 10, 000 or lower. And so when we're looking at a lot of the communities we're serving, we're challenged by the fact that they're small communities.

They may not necessarily have the normal infrastructure that communities have, and we don't even have that big population base that we can rely on to centralize everything. And so even though we centralize a lot of our services, we're actually decentralizing a lot of where the people are at. And so it brings a unique challenge for us not having a large population base to center things in.

We don't have a center, so to speak. We're very much a diversified mesh as opposed to hub and spoke we've got a mesh network across the way we do everything. For me, I actually started the IT department here about eight years ago, and I've gone through seven mergers in that time and not a single one had an IT department.

They were all these small FQHCs that were serving one community, and obviously with the changing in economics, that just isn't a sustainable model. And they were, looking at trying to find partners, they had a lot of third party IT, and so every time I go through one of these mergers, it's always interesting, because they have a third party IT.

That's generally 300 miles away in a big town and you're walking into a mess and we've just learned that you just rip everything out and start from new. And we put in our systems and it's all stuff that we can remotely monitor because I can't put staff at every single site. These communities are so small, the health centers, there's no way to justify one staff.

So we're trying to figure out ways of centralizing, but also decentralizing, and making sure that, if I get half the size of the IT person, we can actually support the other half via that. Yeah, when we talk about staffing, that is definitely one of the big challenges that we have, just because we don't have, big population bases to draw from, and people a lot of times don't want to move to these really small towns.

Yeah, interesting. Welcome back to attracting and retaining talent in a minute. Daryl what about you? What are 📍 you facing? What are distinct?

I think to Scott's point we came as a post merger acquisition a group of critical access hospitals coming together.

So we had to standardize on an EMR. So there was A collapse of five individual EMRs into one to make one universal record. Definitely a lot of challenges with that, but I think the better side of that, and that's always there. Challenge is unique. I think a lot of the challenges in rural health care are also experienced in more metropolitan areas.

Staffing is an issue. We watch labor costs go up and up, and contract labor is just a big challenge for the majority of it. Retention and recruitment of IT staff, even though limited, is still a challenge throughout the entire area. In rural health care, I'm not sure about others, but aging populations, there's financial strains, they tend to not be the healthiest group of patients, so that the health care that they need is typically more acute.

And I think overall, when you look access to resources whether it's infrastructure could be transportation, could be telehealth, I think to maintain equity amongst all of your patient population is a big challenge, I think more so than you would see in some of the more metropolitan areas.

But to me, those are some of the bigger challenges and Bill, there's, we can go through and through, but there are a lot of challenges within rural healthcare.

Yeah, I lived in New Hampshire for a year and. The reason there's acute issues is because if you go to any of the fairs there, there's absolutely nothing healthy to eat from one end of the fair to the other end of the fair.

But it's amazing. Funnel cakes and just amazing food. Anyway, but I digress. real quick flash question here. Daryl, how many IT staff do you have? I have 29

staff currently in place. We cover all business clinical analytics business functions data analytics departments.

Pax, imaging, those types of services. And our current, I believe our current employment overall is 1, 025 employees. So we're running about 3 4 percent of the total

staffing. Alright, so 29. Ryan, how about you?

Not counting myself, I have 6 IT dedicated staff members. That's really IS services. Our data informatics is actually spun off into a different department.

And then I also actually oversee the telehealth department, so I've got a telehealth program manager there as well. And overall, we have about 280 employees.

Scott? So we

have about 170 employees total, so we're pretty small. Actually, for the county, we we're one of the largest employers.

But in the large scope of healthcare we're very small. But our IT staff is actually fairly stable. we have five IT staff plus clinical informatics and we're expanding our clinical informatics department. And that's been one of the strategies that we can perhaps get into later but we I've really invested lots of resources into our clinical informatics function.

Hey, just out of curiosity, do you put your hands on the keyboard? Are you in systems, in that kind of stuff? Yep. Yep. Yeah, all of you are shaking your head yes. Yeah, that's, I was in a group with 14 CIOs. And I talked about the fact that I wouldn't hire any of you to run a rural healthcare.

System because none of you are qualified to and they just looked at me like, what do you mean? And these are some very large systems. I'm like, you couldn't do it. Like you have to know security down to the, sitting on the keyboard and looking at the routing tables and doing that kind of stuff.

it's a different job altogether. And

I think part of that goes back to your staffing too. So like I have one network administrator who he's got 20 years of experience and I am very thankful for him. Most of the people I'm hiring beyond that are very raw. And so I've got to be able to do those things as I staff up.

And as I train them, it's it's definitely not an administrative position. There's definitely much more of a hands on position because eight years ago, it was just me. Like I put most of these systems in place personally.

I'm gonna start going into the participant questions, which means this can go in any direction.

But for those of you who are on we collected questions ahead of time on the registration form, and so we have a good 30 some odd questions, but if you have other things, go ahead and put them in the chat and we will see if we can get to them. I'm just gonna start Going down here.

What are the ways that CIOs are addressing security in an environment where staffing shortages and budget constraints are a challenge? who wants to be the first one to take one of these?

I'll go ahead, Bill. I'll take one. Security is is always a challenge. But I don't think, unfortunately, in a environment the resources are more limited, but the requirements are still the same, regardless.

I think if you're fortunate enough to be able to get an expert in place, I think it helps. And I think day to day operations and management of those, education being a big one I think is clearly involved. But honestly, you have to start outsourcing some of those remotely. You have to look at those monitorings.

I have to look at things that go bump in the night and have a resource that's going to be out there to be able to help me to be able to handle those. My staff just can't do it. Yeah. And I think from what I've heard even some of the larger organizations are having to do the same thing or at least a hybrid of some sort.

Anything the two of you would add or? Yeah, I think one thing

that's important is yeah, the staffing, I don't know how much you ever go with staff all of it because so you are going to have to go outside. And I think where the budget constraint questions really have to come is getting rid of a lot of those constraints by having really honest conversations with your leadership about this can cost you this much now.

Or it's going to cost you 40 times to a hundred times as much when something goes wrong. And thankfully, I think there is obviously, as much as it's in the news all the time, my CEO, every time now that there's a ransomware attack, I'm getting a message saying, Hey, are we protected from this one?

And so I think having that awareness that leadership gets rid of a lot of the budget constraints for us. And there are. For rural healthcare and stuff, at least for us, there's partners that are willing to give us some funding to help with that through grants. So that is another potential resource that you

can find.

You know what's interesting? It's, we used to think that anonymity, because you were so small, that they didn't care about you, they weren't coming after you. And as we saw with Sky Lakes Medical Center, which is I think smaller than most of you guys they are going after smaller organizations, and there is. potential for even a 10, 000 check, they're going to shut you down and see if they can get you to write the check. Let's go to this one. What's the best win on software consolidation? Are you guys focused on consolidation? Is that something you're looking at to simplify the environment, maybe drive out some costs?

You're all shaking your heads. Scott, I'll go to you.

Okay. Yes, it definitely is something on our radar. And so as we are going through the EMR ERP vetting process, we are, the IS team is having a parallel conversation around assessing our tech stack and making sure, getting a better idea of all of the various, pieces of software that we have across the enterprise.

And so we've already uncovered a few duplications, and so we're very much in in a phase in our journey here to consolidate our software. And and it will really accelerate once we choose, what EMR or ERP system we will adopt.

But right now we're preparing for that time.

And Ryan you've already mentioned this a little bit. When you... Acquire a new entity, you guys just don't even mess around. It's no it's all gone. We're coming in. We're, yeah,

this is our defined hardware. We have a defined hardware, like everything from what laptops they're on to define the software.

And generally we actually, if we announce a merger, let's say last year we did this, we announced a merger for May, I think we announced it in January. Obviously, I was aware of it before, but we announced it publicly. We actually signed a MOU with them that we became their IT vendor in March when their IT contract ran out.

I actually had three months before and all the rest of the merger activities happened to go in and replace all their equipment, replace their software, get them on our platforms. Our big wins, Microsoft, 365 platform, CloudBase, we run, I try everything to keep it in there. Obviously, Like we tried it for project management.

It didn't work. So we did kick that out. So just because something goes into the Microsoft doesn't mean we leave it there. But then the other one for us, it's been a huge one is TitleCare is our telehealth platform, but it's also a remote patient monitoring platform. It's also a clinic to clinic telehealth platform.

So pretty much all things telehealth in one platform, including remote patient monitoring, that was a big win for us.

Daryl is software consolidation a focus for you guys? Absolutely.

Yeah, we're still working through it. I mentioned that we had just, 5 EMR migration into a single EMR, but, where we saw a lot of savings was, I think it was 45 plus ancillary peripheral supporting software packages that were blended into these environments that we were able to pull together.

Cost savings were significant by the time you're done collapsing those into those, and the licenses tend to extend a bit further. We are definitely an Office 365 shop as well, and honestly, that was a game changer from an operational perspective. We do use some of it for project management. It is challenging, but Teams has been the big win.

We use it from both a clinical perspective as well as operations.

Wow, this is a interesting group of questions. I'm so sometimes I avoid the security questions because I don't want you to reveal your security posture to the world. And so I'm trying to stay vague on some of the security questions here.

But there is this question of the cloud, I'm going to stay away from this, the question is how's rural health care securing health staff and patient cloud data and applications. I don't really want you to talk about that, but what I do want to talk to you about is cloud specifically.

Have you been looking at cloud as a Strategy and how does it help rural healthcare? Daryl we'll start with you. Yeah,

We have a, it's a hybrid environment. We have definitely have operations that are in a cloud based environment, software as a service environment. They are there.

There's no doubt. And I think the approach you take, I don't think the security implications are any. different than they would be with an on prem solution or any other partnership. The key I have discovered is the upfront vetting of reputable partners and providers to be able to make that work.

It, you need to spend your time there because once you're in the relationship, you're there, it's very hard to move. So to me, all that upfront work is where we've been successful.

That's interesting, Daryl, and we just adopted a similar procedure where we worked with our materials management or supply chain manager to, put together a basically a two sheet evaluation of any vendors, because even that may not have, that aren't like a software as a service or, traditionally tech, everything involves some sort of tech aspect at this point.

So every service or every program or every piece of software we run through the vetting process, and then we all come together and do a vendor evaluation at the end to, really go through each aspect. So that's it's very important to us that and really interested to hear your you faced, similar issues with, vendors and things like that.

But yeah, it's very important to choose the right one.

So I can wander a little bit into the security side of it. For us, one of the reasons we actually attracted the EHR we use is it is a SAS based EHR as opposed to taking a server based EHR and moving into infrastructure that's just cloud based because then you do have a lot more security like things you have to figure out versus if you have a SAS based, you are taking a lot of that pressure off of your staff.

Obviously, I still have to secure credentialing if you have things like single sign on, but that's just.

In a small rural place, it can actually help with some of that. Obviously, have good partners. I love Microsoft. People are always like, when we first moved to the cloud, just so we're like 98 percent cloud based. We're a fairly young organization. So the only thing I still have left on prem right now is print servers and Active Directory credentials.

That's it. Everything else, we're pretty much completely cloud based. And for an organization like us, it's so I even tell people this according to Hearst's definition, we're not even rural. We're what's considered frontier. Oh yeah. Which means we have less than six people per square mile in the areas we serve.

Is like where I'm at in Hardin, we used to have a server. When I first came on, we had a, our EHR server was in Billings, which is 40 miles away from us. I had a 60 second ping time to that server because of it wasn't going direct to Billings. It was going from us to Denver to Billings. And then Ashland, which was 110 miles away.

They were going Seattle to Denver to Billings. So I had 200 millisecond ping times on my server. And I'm like, I can't put a server on Ashland. I've got three staff member there and they're seeing a hundred patients. And so going to cloud based where it eliminated

a lot of those variables. Because your cloud's in Seattle or in Denver.

Yeah,

And all I'm having to do is worry about what my my, and a lot of them, a lot of those clouds are in both, depending on what you're like, they're looking at that. And really helped us out. Going cloud based was something that was a directive when I came on board and we jumped full scale into it and it's funny because eight years ago, all the other CIOs were looking at me like I was stupid and had no clue what I'm doing and now they're all calling me saying, hey, how did you do that?

Because. It is the reality we're in now.

And your response to them is, how do you not do that?

Seriously, I have no clue how, of course, I'm young enough that I do not have a massive server background. I did not grow up in servers. I grew up in cloud. So that's my background.

Wow. Yeah, you 40, I'm going to call you guys the 486ers.

The EHR in the cloud. It sounds Scott you're looking at somebody else hosting your EHR, essentially, and Daryl. Expanse is hosted, correct? We are

hosted on prem currently. But we have a hybrid model with our DR. Our DR is completely cloud based. Not as a software as a service, but truly cloud based.

Man, that's fascinating. Let's see. Some questions here about what would make the biggest difference for you to assist in your hospital day to day operations? Your day to day operations that are going on, What would help the most? What would clinicians say, Hey, if you could do this for me, this would really be impactful.

Darrell, I'll start with you.

cLearly in our environment would be any kind of automation EMR enhancements that we could do. We're counting clicks with them. We sit beside them trying to look at those, whether it's a compliance requirement, an operational requirement, trying to reduce those, trying to find operational efficiencies wherever we can.

We're currently in a Nuance DAX Express pilot right now. Huge pluses for those. It was Mhm. Definitely a better model than the original Nuance DAX model. The Express has made a big difference. we've got pilots of ChatGBT working without, within the system, which is something we had to build a policy and put some framework around.

when you look at the models at how. We're not putting, PHI in this model. We're talking about just operations. They have to do discharge instructions. There's a lot of things that they have to deal with on a regular basis. I think that was very helpful for them. So I think anything we can do to automate and improve the efficiency of the providers, because they are struggling and burnout to me is a real thing.

talked to a friend of mine yesterday. And she went in for her annual visit to her health system. And it's a large, major health system. And the person who she was meeting with was clicking and doing stuff on the thing. And she said, what are you doing? the clinician who was actually seeing her said, I tell people my full time title is professional clicker.

Because everything was a drop down box. And it's interesting that we're still there and it doesn't matter if you're. large health system or small health system. There's still a lot of help that people are looking for to just, Hey, ease my way a little bit here. Like I meet with a bunch of patients a day.

It would be better if I could automate some of this stuff. Ryan, how about you? What would make the biggest difference from a clinician perspective? So my goal is

something I just learned about a month ago at a conference I was at and the Ohio state was talking about, they're actually working on moving their providers to cell phones instead of laptops and computers, because it mandates a lot more automation and a lot less clicking.

Cause if you think about what you can actually do on a cell phone versus, what we expect to provide us on a laptop. And so they've done it via combination of. Dictation and then AI being able to take that dictation and actually chart with it as opposed to them having to click through the charts.

And so I heard that and thought, man, that's my goal. Cause my clinicians would love that. If if they don't even have to sit down at the computer, they just, when they are walking out of their room, they just talk to their cell phone and a cell phone that we give them and say, Hey, this is everything that happened in the AI and the dictation takes it.

Our clinicians are going to love that. I don't know how far away I am, but I'm going to figure out how to get there.

My experience on my banking app on my phone is better than their web interface. And now I can do more things on the web interface. But I could do Bill Pay, I could do so many things on that phone.

Bill, my experience with my mechanic is better than what we can deliver in healthcare right now. It's crazy.

Absolutely. Yeah, the mechanic has an advantage, right? None of us are agreeing to put like a hundred sensors on us so that when we show up to the health system, they have all these stats.

It's hey, for the last two weeks, you seem to be, this or that. But when our car shows up they know everything there is to know about that car. Yep. Scott what about you? What are some things you're looking at that could potentially really improve the Clinician's Day-to-Day?

Great question and Darryl and Ryan have already touched on a few things that we are doing. We're also piloting a nuance solution and and I just learned about that, I guess about. Six or eight months ago. And I really feel like that's gonna be a game changer. We'll include that in our EMR conversion.

And also the cell phone piece that Ryan looked at. As we we've demoed a couple of the epic cell phone options. I think it's KU or there's also, there's an iPad version and a an I like a cell phone version. And the doctors already are chomping at the bit to get at it.

So I think, both of those things will really help. But then also, just in terms of a non tech game changer is the I think, Daryl touched on this about, sitting with the providers. The investment in our clinical informatics department has really paid off, even with our current, EMR.

And I think it will continue to pay off when we convert. And we have a fairly clunky EMR that frankly takes a lot of clicks. It's not intuitive. So it's not an Athena. We had Athena for a while and we, we actually, the clinicians loved Athena. But then we, for various reasons, went back to CPSI.

And the investment in sitting with the providers, watching them work really reviewing their workflow, paid off, and we'll continue to do that.

curious if you guys have, and some of the questions that are coming in. James seems really persistent on this, trying to understand how you justify staffing.

And the question really is around, do you have ratios? Do you have a percentage of the overall spend of the organization or operating income or something? That dictates how much IT staff you can have.

I tend to follow some Gartner metrics, which, which will provide a percentage of FTEs and also a percentage in our case of expense as opposed to revenue.

Revenue is a really difficult one to check to predict in a rural healthcare environment with contractual agreements. We typically are at 4 percent of FTEs. And we are, as I mentioned earlier, somewhere between 3 percent and 5 percent of overall expense.

Of total FTEs, 4%, 3. 5 percent of total expense.

Okay, that makes sense. Do either of you want to share how you... Come up with your staffing. We, I'm working towards

getting some more definitive guidelines and it's partly because the organization, I said, we merged so many times and none of them had IT, so they were all at 0 percent for staffing. And I don't even know what percentage are paying for these third party IT.

And so it's been an education system of we're just trying to get caught up as much as anything, because none of them had staff, so we're hiring. I think, and it's also a little weird because I think Daryl mentioned you, you actually have informatics and data in your department. For me, informatics and data, we actually spun off to its own thing because they're controlling both the data going in and the data going out.

And so like my ratios are probably fairly close as to Daryl's, if I include that staff, that's not part of my department. But if I look at strictly IS services, the number that I've been told by my leadership I can shoot for is about one for every 34. So about 3%. We're not anywhere close to that.

Yeah.

And for us it's similar. We are working toward a set of metrics, particularly on the FTE side. I'd like to break this down according to total total IS cost for the organization and also cybersecurity spend because I want to make a point about that, but our total our total IS cost percentages, about two to three percent depending, and that's growing largely because of our investment in clinical informatics and cybersecurity.

And so I set a goal of increasing, when I came in four years, five years ago, at CIO. we basically did not have a cyber security strategy, which was shocking. So we, have been working toward that over the last four years and steadily increasing our spend every year. And for now, we are at about 15.

If you just think about cyber security dedicated Functions, software, et cetera. We're at about, 20 to 25 percent of our IS budget, just dedicated cyber security. But then, but I feel like It's probably larger than that, just because, it's difficult to, to measure what everybody's doing at a task based level but that's generally, and that's growing because really we're investing heavily in cybersecurity and we've done a lot there and also in clinical informatics,

we're pretty close, Scott, I think, because we're, overall, I mentioned, we're probably between. I'll say between 4 percent and 5%, Neva, but about 3. 5 percent to 4. 5%, but give or take, and I think about 18 percent of that is dedicated to cybersecurity. But once again, how do you slice and dice it?

There's definitely a lot.

Exactly. Yeah, it's difficult to slice and dice, yeah.

Thing to consider. And I've actually had conversations with some of my VPs about this is there's actually some research out there and I'd have to go hunt it down that generally organizations that are growing or wanting to grow are going to actually have a higher percentage in their IT departments versus the organizations that are stable.

And if you're not planning on growing your stable, that number can actually go down versus if you are trying to add on new services, you're trying to bring a new project, any more, I laugh every time somebody comes to me and says, Oh yeah, this is just an inter department project.

I'm like, you need no IT help for this project? Oh yeah, I don't need it. I'm like, okay, I'll give you three days.

you just want to say

liar! We've actually had a lot of conversations because, they just all set up these own little projects okay, you'd have to do one of two choices.

Either cut down the number of new things you want to do or give me more staff. And it's easier for them to give me more staff, I've discovered. So

It's interesting because in organizations. of your size. you get a little bit larger, you will have governance in place. And you'll have somebody prioritizing projects and doing all those things.

But the smaller you get, sometimes those things are literally just meetings. Just hallway conversations of, hey, we need to do this thing. And and formal governance is hard to come by. And we're in

the middle because we are growing we have governance for big projects. It's the, oh, I want to add a time clock to this clinic. And then actually, six of the clinics want to add those time clocks. And I'm like, okay, you guys, that means iPads, it means mounts, it means I have to get an electrician in because where you want that iPad, there's no place to charge that iPad app.

And it's those little things. We are actually in the process in the next couple months of pulling all those formally into our project management team, because you're right it's what we're discovering. It's too many of the hallway meetings that, yeah, for them, it was an idea. For me, it's what

the hours are worth.

I'll tell you what, Ryan you scared me before just talking about the network. And I thought about at St. Joe's we had to go to rural Northern California. It literally was in between Sacramento and nowhere, actually between Sacramento and Bend, Oregon, essentially, you get the picture, there's nothing there.

And my gosh, getting the carriers to figure out how to get in there. And then the latency to that place and stuff, I can only imagine what you guys. Have to have to deal with, I'm gonna come back to a question here. How are you managing the legacy systems? For instance, the EHR that you replaced. How are you managing that data?

Are you keeping those legacy systems up in read-only mode? Are you moving them across and shutting them down? That's the genesis of the question. And I guess Darrell, you went through an EHR migration. Did you keep old things running or did you. Shut them down, or would you do?

it happens in both cases. So I think with some of these systems that we've we kept them in read only format for a period of time. Typically to spin down AR, those types of things that are in those environments. We did create a repository for data, and we migrated a lot of the information in there.

Keeping in mind that financial information, particularly in a rural setting in rural health care there's cost reports, there's a lot of audits that need to occur for a period of time. A minimum of seven years, and then of course, seven years past the age of majority for any clinical documentation.

That's going to be kept for probably 28 years. Everything gets archived from a clinical perspective. My goal is to retire all legacy systems within two to three years post migration. Hopefully a little sooner than that, but that would be the maximum, and then retain all the other data. Extraction is expensive, and it's difficult.

Hey,

darrell, I just want to commend you for knowing those numbers. The first time I went to my staff and I said, Hey, what's our retention, and what needs to happen? They just looked at me like... Forever? I'm like,

really? Forever? There's a risk with keeping things forever, and we've found that with the discovery process, it can be very challenging.

It can.

Yeah. Yeah, no, that's fantastic. Anything to add? We don't all have to answer the questions. If you have anything to add, that would be great. We're almost identical to

what Daryl said, so I'll just ditto him.

And I'll just add that it's been very interesting because we have two legacy repositories that we are now trying to architect into, the EPIC, into an EPIC archive.

So we're, we're right in the middle of that right now. So it's very interesting that that were all on the same page, but at any rate I'll just add that it's very difficult and very expensive.

Let's see what are strategies you have found most effective in fostering community buy in and engagement when implementing EHR or even your security things and those kind of things?

How do you get buy in and how do you educate and train at the front line? I'm sure this is pretty easy. It's a small geography as we covered earlier.

I'll start. We we have as part of our implementation plan that we're developing for our conversion to Epic we have a strong marketing and outreach program and plan.

And we, I have, and again, I'll loop back to the benefit of having a strong, stable CEO. In addition, he is very community oriented and he has already been out in the community at various Rotary meetings and civic organizations at the chamber, talking about our strategic plan, talking about that we have an EMR adoption, conversion coming up that'll ultimately benefit the community.

So from a patient. From a business facing standpoint, I feel like for the first time we have a plan. Our executive team and board are talking about it. And at the frontline level, we have a high appetite for change. the conversations I have with providers and frontline staff are pretty easy at this point.

And we have a lot of engagement with with the demonstrations that are going on. we have a lot of folks who are, watching the recorded videos which, I haven't seen that before. So we have both internally and externally, I feel like we're moving in the right direction.

I think, one of the challenges that I'm, keeps me up at night is just, That positive energy around the conversion, because once we get into the details, as you all know, it can get a little dicier, but at the same time I feel confident we'll do

do the other two of you rely on at the elbow support or do you do more training videos? Do you do a lot of zoom training and that kind of stuff? What's the approach there? In person to

start teams

afterwards.

Yeah, we do probably the same model. A lot of in person at the elbow going further.

one comment I'd like to make to Scott is that we discovered as we went through the process and thinking about engagement in the community is offering out some of the new services. But when we collapsed our EMRs we realized pretty quickly that you also have patient portals. And the data that's stored in those portals EMR.

So you're maintaining multiple portals. Our patients were happy. Many of them had shared. Up to five patient portals based our geography of where they could get their information from. So very challenging.

so you guys have your own language in rural health care as well, and I'm going to be honest with you.

I barely understand this question. Do you expect USAC to continue its role as administrator? Why or why not? USAC, I think, provides rural Broadband, is that? They do.

I hope that they do keep, it's a godsend to us because the cost of that offsetting up to 60, 66 percent of your carrier costs.

I sit on two broadband committees trying to get, the best connectivity we can into the into the homes for people. Typically, rates are good internally from hospital to hospital, but telehealth, virtual care is a big challenge, and I hope they're going to keep to maintain

those.

So telehealth is a big initiative for all of you? Yes. It would have to be, it's just based on the geography, so broadband becomes just absolutely critical, but I assume you're just doing plain old telephone.

We do video

primarily. Yeah. Video primarily.

Okay. almost all video.

Yeah. Same.

Yeah. 95

percent video. And then even within clinics, we're doing video with peripherals and we're actually trying to push with remote patient monitoring, obviously video with peripherals into the patient homes. Yeah.

Yeah.

Same. We can save them a hundred mile trip for a primary care visit. We're going to do it.

have a question for Daryl and Ryan, if you don't mind, Bill. Please.

This is your tryout to see if, you can host a show. No, not

at all. Not at all. That's your job. Ryan and Daryl, do you have any idea what percentage of telehealth visits you do? Eighteen.

18%. Yeah. Yep. I think we're at like eight to 10 right now.

mean during Covid we were a hundred percent behavioral health. We're all telehealth.

Yeah. Yeah. and that's one thing. We're at about eight, 8% right now and we have a growth goal to try to get to 20% because we have a lot of people delaying care because of transportation issues and things like that.

And we just hired a care coordination manager who's gonna try to. Work on those more kind of social determinants of health issues, then, connect them with resources. But we'd really like to grow that because, there's gap.

I like this, by the way, if you guys want to ask each other questions, by all means, this is actually, I like this.

So

for us, the interesting thing about telehealth and the growth within that is when I came on board, one of my early initiatives was actually clinic to clinic telemedicine, because, again, we have really small clinics, we don't have a big population base where we're even like, hey, we're going to use this as the hub and spoke out.

So my psychiatrist, We have a full time psychiatrist, which for FQHCs where we serve is an anomaly, but she lives outside of Bozeman because that's where she wanted to live. Our psychologist lives up on the Canadian border, and our nurse care manager for them lives in Lewistown. And so not only do we have to use teams to communicate behind, but we're using telehealth.

That psychiatrist is seeing patients at 13 sites. And so that was our initial goal was like, how do we get clinic to clinic telemedicine figured out? And so we spent pre COVID years. Got that button down, have a great platform. There's always workflow questions, but the actual platform is great. Technology is good, the people is the hard part.

Then COVID hit and we obviously, like everybody else, dove headfirst into direct to patient. We got to get this. And the platform adapted to it very well. We were very thankful, great partner. But coming out of COVID, I'm having to help people understand that it doesn't make sense for us to have patients coming to a clinic to do a telemedicine when they could just do it from home and we don't tie up a patient room.

Even if it's not in your clinic, your type of patient someplace else, and it's actually been an interesting trying to get people to use direct to patient telemedicine as opposed to coming to the clinic. And the clinic's always a great option if you do have people who have bandwidth issues, but so much of it is just, they just want to schedule in person.

It's no, actually try to keep the patient home. We're going to save ourselves a lot of money. We're going to save them a lot of money in time. And that's been, for us, the biggest growth in the last couple of years, is actually trying to transition as much clinic to clinic telemedicine to patient

telemedicine.

That's really interesting.

Bill, if I can, since we're asking questions, I have one for both of them as well if it's okay.

Yes, please.

Do you leverage any third party tertiary telemedicine, virtual care, thinking in terms of, we use tele ICU, we also do teledermatology, some of those specialty practices where we can't bring them in, and we partner and bring those in.

Thank

you. that's a really good question, Daryl, because we're right in the middle. We just completed our community health needs assessment and one of the things that came through on that were those specialty needs, and which, every time we've done it, that's pretty much what comes to top.

But we're, we've just started a feasibility study on the top five specialties and DERM was one cardiology was another one. So in the future, we will likely establish those, third party telemedicine relationships, but right now we're in the feasibility study stage.

And we're, so because we're primary care, like tele ICU is obviously not something we're concerned about.

Almost all the hospitals around us use tele ICU. As far as telespecialists, we actually hire our own. So we have our own psychiatrist, we have our own dermatologist, and then from a profitability, which, as FQHC, profit is not important, but we need to pay the bills so we can provide more care to more patients.

We're not trying to make a profit, but we are trying to stretch the dollars as far as we can. We save a lot of money by not third partying any of it. So we actually have no third party telehealth offerings. That's interesting.

Alright any other cross panelist questions? Not just yet. All right, so let me ask you this.

I wrote an article a long time ago, and I said the role of CIO is three things. One is keep the trains running on time. The second is to lay new track, and that's your new EHR, your new ERP, and that kind of stuff. And then the third is to build airplanes. I'm curious, what would building an airplane be?

What would enabling the next, round, or what do you think that's the most innovative thing that you're thinking about right now with regard to rural healthcare and supporting your clinicians, supporting the health of your communities? Is there some things that you're thinking about that you're like this could be a game changer for us?

I will go from, you guys can't see my screen. I'm going to go from right to left this time. Scott, what's the most innovative thing that you're thinking about right now?

I'm not sure that I've given myself much space to think about this because we, for me, innovation is pretty low, we have a pretty low bar.

We're the innovation that we're looking at is just getting into an EMR that is functional and streamlined. Yeah,

It's, yeah it's what I would call incremental innovation. It's like incremental innovation a lot better than what we are doing today. A lot better.

But within that, I'll go back to, Darrell's point before about automation.

That is the thing that I think about all the time is, what kind of tools can we innovate can we introduce that will provide a more streamlined, EMR experience and workflow so our providers and our clinical staff can, spend more time with patients, so we can grow volume in our clinic and in our ancillary services.

So we can be more efficient and not have as much, downtime. So those are the things. And, we've already mentioned a couple of products, Nuance and ChatGBT, but, that's the thing that, that I'm really focused on.

Fantastic. Ryan, how about you? My, CEO's

favorite phrase is that we're building the airplane in the air. So that kind of tells you usually, I find out after we already took off what we're building. For me, it's trying to find, and I'm going to echo Scott with the the clinician stuff, like trying to increase productivity, not like in the negative context, but like, how can I increase the number of patients they see because they're that more effective at seeing patients and less than all the time charting.

The other thing that for me right now is a big pressing need is. patient experience. I think we've always joked healthcare, when it comes to patient experience, we're really behind the ball when it comes to patient portals, as opposed to, like I said, online banking. We're so far ahead in online banking as opposed to what's your online portal like?

Is it as good as your online banking? And then even when they come into the clinic, what those experiences are, we got some data back about the average amount of time our patients were spending in the clinic for a 20 minute visit where they only saw The provider for 10 minutes, they were spending over 60 minutes in the clinic.

And it's okay, guys, we got to find ways to make that better. Because unfortunately that's the norm. That's what we all brace for. Whenever you go to see the doctors, you're going to spend 20 minutes before, at least in the waiting room. And so trying to find whether it's automation, whether it's technology, whether it's data, finding ways to make it so patients, we're being a lot more patient friendly.

And that's really what I'm trying to figure out is what do those look like? How do we offload some responsibilities to automation, to centralize, so that people that are left in the clinic can focus on having the best patient experience possible? Because all the things that don't need to be done in that building can be done either automatically or by somebody someplace else.

And Daryl, you're going to get the last word. Both

Ryan and Scott, very good points. I think the patient experience definitely something that we have to improve upon and is a primary focus. Scott's point of view, also looking at, automate things. I think the holy grail for, I think, healthcare going forward is going to be AI, and I say AI, I'm using that term very loosely, it consists of, artificial intelligence, deep learning, natural language processing, generative AI, process automation, all those things, predictive analytics, prescriptive analytics, the list goes on and on.

To me, I think that's going to be the key, and anywhere we can improve the experience for the patient, but also for the clinicians, because they are probably one of the biggest commodities now, we're all out of business if we don't have clinicians in place. Making their experience better I envision the EMR of the future, if it is such a thing as an EMR, real time genomics being brought in, being able to look at that patient, social determinants of health using predictive analytics, saying this is where that patient is going to be.

To me, That is what the airplane, I think, Bill, for me that's the place I'd like to see us

be.

Yeah, hyper personalization of healthcare. They're going to know us by our genome, they're going to know us by the monitors that we provide information like the car we discussed earlier, and then care will be very specific to each individual.

I think we're a little ways away from that even if you lived in... LA or New York, I think you're still a ways away from that. But the promise of that is I think that's something that could scale down. to rural health care very well and really give us some opportunities. Gentlemen, I want to thank you.

I want to thank you for your perspective. I want to thank you for your service. I know how challenging your job can be. I sat on a panel once with a person with a five person staff, and I had 750 people on my staff, and I just felt guilty the whole time. Because they're asking me questions, and I'm like for security, I have a person who does this.

And she said and she was very well versed on all the different things because She was heavily involved in all of them. And I was just amazed. I was just amazed at the level of of professionalism and the level of knowledge that it takes to run an organization of your size.

So thank you very much for your time.

So that's all for today. It's going to feel abrupt, but I'm going to hit end and we're all going to be cut off at once, but gentlemen, thank you very much. Thank you.

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