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February 13, 2020: We are so happy to welcome two of the industry’s best, Sue Schade and David Muntz, of StarBridge Advisors, onto the show with us today. They are decorated veterans with more awards between them than fingers on our hands. This episode, which is the first of two parts, is a Jeopardy-like interaction, where Sue and David tackle some of the health IT issues that are sure to shape 2020. We kick off by talking about EHR implementation and David shares his unconventional opinion as to why a single-vendor approach does not work. Sue also sheds light on what we can and should be doing to ensure that clinician burnout with these systems comes to an end. David and Sue also touch on governance, where David provides fantastic insights into the different types of governance that we need in these ever-evolving times. Finally, we round off with talking about IT budgeting, where Sue points out the need for tight budgets while still ensuring all needs are met. This was a fantastic discussion, so be sure to tune in! 

Key Points From This Episode:

  • Sue’s take on EHR implementation and why it’s heads down during optimization.
  • Why David believes that it’s important to have a multi-vendor environment with EHRs.
  • Learn why merging organizations often does not make much sense.
  • Will we get better at clinician burnout around EHRs? Sue’s predictions for the future.
  • Find out where David think the greatest need for governance is and how to solve it.
  • Data, if not harnessed and governed correctly can drive clinicians even further away.
  • Why organizations should use the word, ‘demonstration’ rather than the word ‘pilot.’
  • ERP’s are an under-investigated area where efficiencies can be increased.
  • There is a need to educate executives and boards around costs of maintaining IT equipment.
  • How IT budgets can be structured convincingly and efficiently
  • Hear more about David’s innovative work with budgeting
Transcript

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 Welcome to this Weekend in Health, it influence where we discuss the influence of technology on health with the people who are making it happen. Today we talked to two of my favorite people in the industry, sche and David Mutz from Starbird Advisors. They are industry veterans. They are highly decorated CIOs of the year, innovation Fellows, you name it, uh, they've done it all.

My name is Bill Russell Healthcare, CIO, coach and creator of this Week in Health. It a set of podcast videos and collaboration events dedicated to developing the next generation of health leaders. This episode is sponsored by Health Lyrics. I coach health leaders on all things health. IT Coaching was instrumental in my success and it is the focus of my work at Health Lyrics.

I've coached CEOs of health systems, uh, CTOs, CIOs, uh, you name it. If you want to elevate your game into 2020, visit health lyrics.com to schedule your free consultation. I recorded this episode in late 2019 prior to our studio move. A couple things about that from a timing standpoint. Sue was in the middle or just getting ready to do a, uh, an epic go live for a health system in which she is now completed and, uh, several months past.

Um, my sound is actually not that good 'cause we're in the middle of the studio move, but Sue and David sound great. We play a little health it jeopardy. Uh, I give them about 10 topics. They select the topic and we talk about the state of the industry and where things are going. Uh, it's, it's a lot of fun.

I love their wisdom and, uh, they just do a fantastic job, great guests. I hope you enjoy. I. Today I'm excited to be joined by two leaders of Starbridge Advisors, previous guest of the show show, uh, Che and David Mut. Uh, good morning, you two. Good morning. Morning wwe and, and you guys are kind enough to be testing out this new format for me where we're trying to do, uh, three guests.

Uh, we'll try not to talk over each other because the video sort of bounces between us, but, uh, we'll,

you're. It up by saying highly decorated industry.

Yeah, innovation Officer of the year, innovation officer, legacy award winner. You guys have seen. Seen. And today we're gonna do something a different, we're gonna state of. I have eight categories and here's what we'll do. We'll just, you know, we'll do it like a, uh, we'll do it a little bit like a game. I'm gonna put out the eight categories.

Uh, Sue, you can go first by picking whatever category, and then what we're gonna do is we're about what's the state of the industry, uh, health it today. And what's the next step? Where are we going? Not maybe what's 10 years from now, or five years from now, but what's the next step? And so the, the eight categories, are IT operations and security?

it, budgeting, governance, EHR, implementation, stop optimization, mentoring and training, staffing, innovation, and uh, experience.

This episode, it's like Jeopardy. Okay, I'm gonna take EEHR. Implementation. Optimization. Yes, because that's right where you're right now.

And potentially what's the next step for us? Sure. So, uh, you know, state of the industry versus a place I'm working right now where we have a big epic go live in 42 days, something like that. Um, you know, overall I think a lot of organizations have the EHR implementation behind them. You just. You get that sense looking at the industry at this point, however, um, there are still pockets where that's not the case.

And due to merger and acquisition, there's still a lot of implementation activity going on. Um, and I think those organizations that are in the throes of, that are heads down on that. They're not . Focusing on telehealth, which has become table stakes or, you know, digital health and consumer engagement. You know, obviously they're dealing with, um, you know, basic operations and security and other challenges that they have.

But when they're in the midst of, um, you know, the EHR implementation and then that post period of optimization, it's just heads down.

And it's, it's interesting because you just gave us three other topics, which we're gonna, you know, digital health and telehealth.

That'll it over to you, David, on this topic, which is, um, there are, there is still a lot of consolidation going on in the industry. So you have, you know, I, I see these, uh, you know, different, uh, jobs that are coming across and different consulting opportunities are coming across, and it's, it has a lot to do with the, with the, um, with the integration of two disparate systems, if not three or four disparate systems.

Um, do we ever see a, a, well, for start with this question, is it, it.

Let's start there. And then the next one, which is, uh, if it is, you know, how, you know, how do we continue to do, you know, maybe walk and chew gum, do that as well as do some of the, uh, other things that are gonna move the. Sure. Well, let me, I'm gonna go ahead and take the less popular approach, if you don't mind.

Um, probably be a little more provocative on this. Um, I've always believed, even though I see the pendulum swinging, uh, that you really have to live in a multi-vendor environment, that you can't escape it. Um, and it's certainly desirable to have.

Vendor. Uh, and the reasons are pretty obvious. People, you know, use the, probably not necessarily nice approach one throat to choke. They talk about the integration they expect to see, and they expect that the products will develop, uh, more quickly. And I'm not sure I agree with all of those.

That the world that we live in is being bombarded by new apps, new applications, new vendors, new ways to do things. And if you really wanna go through a transformation, you can't wait on that central vendor to do the work. Uh, and innovation depends on you being able to have a.

Um, even though a central vendor is important, it certainly is not the only place you should focus and you need to figure out how to do real integration, and that's not just interfaces, that's also looking at APIs and figuring out a way to incorporate new ways of thinking, new ways of working. Uh, and you know, the government and having served in the government during a time where meaningful use was there, uh, people talked about APIs, but the API APIs were limited to essentially pulling data out of the electronic health.

And what I think we missed the boat on completely was the ability for us to say a. From other sources. Uh, and as we start to do analytics, you'll see the data's getting pulled from all kinds of sources, uh, many of which are not EHRs. It's pulling information from census data, pulling information from community services, et cetera.

So I'd like to see us embrace the multi-vendor environment. And I see a lot of companies, you know, I've seen these companies. One of the two big vendors come together and then all of a sudden they take one portion of the organization and they move it to the other vendor, um, because they think the consolidation of the vendors makes sense.

And it's really the consolidation of the data that makes sense. And you're gonna have to do that regardless of how many vendors you have in them in the space. So. Not a big fan of single vendor approaches. Yeah. You know what that is, uh, pretty provocative. Although if, if you've been in the consulting world as, as we have been for the last three or four years, I mean, I've seen those, those, um, requests come in, uh, hey, we just, we merged these two organizations and think about how silly this is.

We're AC.

You know, we just finished our, our, uh, Cerner implementation, uh, a year ago at this health system, but it got acquired. Now we're taking it to Epic. I mean, the, just the whiplash on that organization, uh, from a culture standpoint has to be pretty significant. But Sue, I'll, I'll let you have the last word on this.

What, what's, what, what's next for us? What are we, what are we looking at? Are we gonna get better at, um, optimization? Point. This, uh, whole idea of clinician burnout and clinician, um, fatigue around the EHR starts to, well, I would hope so. There's been a lot about physician burnout. The, the class, uh, arch.

Arch collaborative, right? That whole effort really focused in on that. I've listened to some of the, you know, reports out of that and, and there's the usability factor of the EHRs and there's the training factor. And um, you know, we're in the midst again right now, going back to where I'm working. We're in the midst of the training piece and you know, that's absolutely critical to.

Help address that. Um, are we gonna get better? Um, I mean, we have to get better. There's always lessons learned that the vendors and the consultants are bringing forward from client to client. So, uh, we absolutely have to, and I think what you're seeing, you know, we've all been around a while, um, you know, with, with more, um, foundational products and not doing all the customization, um, that.

That changes the whole optimization piece. Uh, it may open up more needs in terms of optimization because an organization says, well, the, the vanilla just doesn't work for us. At the same time, it may reduce that whole optimization piece as, as the organization tries to get to a more common, um, vanilla's probably a bad word, but a, a more common, uh, common approach.

So, I don't know, you know, that's a tough one in terms of the, um. Uh, you know, what's the silver bullet around optimization and, uh, getting these EHRs to the point they need to be. So, um, we've got happy, um, efficient physicians and clinicians. Yeah, it's, uh, it's interesting, a lot of the CIOs I'm talking to are, it's ramping up and trying to.

Significant, uh, change and lift, uh, for a lot of IT organizations. Alright, so, so that sort of gives us the, this is what it feels like. It's not a deep dive into any one of these, but it's sort of a, a high level. Um, David, if I had to guess what topics, remember it? Operations, security, budgeting, governance, mentoring and training.

Staffing, innovation and experience. Which one would like to talk about? Um, probably governance. Um.

That's curious. Okay. Not government. Government. So anyway, the, uh, the thing that I've noticed is there, the lack thereof, uh, in many organizations. And, you know, sometimes, you know, governance is such a broad category, but people define it generally speaking in terms of demand management, but. It's for data.

We have a data tsunami on us. And you know, I've, I've said the interesting thing about a tsunami is a tsunami would be fabulous if you could harness the energy that's associated with one. But the difficulty is that the water just comes ashore and destroys everything. And I see a similar situation for data.

We get a TMI of data, but.

Well then we're gonna fail. And you know, as we add social determinants of health, all that does is increase the amount of information that's flowing our way. So I would suggest that where we need to focus is on three different things that are all related. And the first one is the data. Governance, uh, which deals essentially with the small elements, uh, then with information governance, which is radically different than data governance, but also is important to figure out how we're gonna take the raw material that's been processed and use it in ways that makes sense.

And then finally, one that I don't. Knowledge, governance, and it's like once you have the information and you've made a discovery that is gonna potentially have a great impact or you've discovered something that's having a harmful impact, how do you take the knowledge and distribute it? And you know, you hear in medicine all the time about it takes 17 years from the time.

Something happens or is discovered until the time we actually, uh, use it in our everyday lives. And so with data and all the information that could be generated and the knowledge that could be spread, how do we take advantage of that? And then finally, and I know it's not necessarily related to the other three, but I think it's uh, probably at a higher level and innovation governance.

Innovation should not be a hobby or a a game. Innovation should be, I think, founded in pragmatism and practicality and you can't figure out how to use all the three things I just talked about in an innovative way to transform what it is we're doing now. Then innovation is, is great, but it's not as effective as we would want it to be.

So I put that governance wrapper around all of those things, uh, and think it's important. You know what's, you know what's interesting is we've heard, uh, death by Pilot is now a, we're hearing pretty often in that, you know, you can, you spin up. It seems like it's no big deal to spin up a pilot, but if you spin up too many of them, you uh, lose focus, you lose energy and.

Potentially people get sort of lost in the whole thing. And data governance is another one that I, I find interesting because I, I talked to Dale Sanders, uh, at the, uh, health Catalyst Summit. And one of the things he pointed out was, um, that we have an opportunity with analytics to show the value that all this work has has meant over the.

Uh, decade or or so, uh, around the EHRI mean, because we're gonna get some, some real valuable data and some real, um, game changers essentially outta this, this data if we, if we work it right, but if we do it incorrectly, we, we stand on a cliff where we could like jam this in at the wrong places in. And really drive the clinicians even further away, uh, because we, we, uh, aren't, aren't doing it in a way that he, he keeps using the words empathy.

Um, but is, you know, I keep coming back to the word design that's designed to help. It's listening and understanding and then putting that data back to work in a way that they're asking for it to help. Well, I think, oh, I'm sorry. But to your point, I think analytics fits on the innovation, I mean on the information and knowledge governance, uh, levels and is just part of the activities.

But what I've seen and just talked to a very prestigious organization, everybody would, one.

Pull data and use it, and it's like, well, who's directing the formulation of the right questions to do the investigations that are gonna mean something? And so it's kind of unharness, uh, creativity and, you know, people can be very innovative. But again. Without having some way to tie together the activities and marshal the resources which are precious in every organization, uh, it really adds more chaos than direction.

And I think that's part of the issue. And by the way, just by pilot, I , I have now advised the people who used to report to me when I was a I. To stop using that word and use the word demonstration. The idea is a pilot kind of infers that it's some, I mean, I infer from pilot that a failure is a potential, used the word demonstration and it's like you've got confidence in your idea and you're gonna show its value as, as opposed to take a chance on the fact that something might fail.

So.

One broad comment around governance is one size doesn't fit all. I yet every organization needs help here. From what I can tell and my experience in the last couple years doing interims, um, uh, every organization I've gone into has had some gap area around governance and some of it

absolutely has addressed. Job of kind of outlining some of the different components of it. I like the point about innovation governance 'cause I think this is something, um, and maybe, maybe that's one of your categories that we can pick, but, um, uh, I don't think people talk about innovation governance so much.

It's more about, you know, who, who's in charge of innovation, what are the different roles, where does it fit so we can get into innovation. Oh gosh. I was gonna say something else about governance, but it escapes me. Go ahead. So, so David, where, what's next? Where do we, where do we go from here in terms of industry or are you talking about activities?

Yeah. So, you know, we try to be pragmatic on this show and, and, uh Oh, sure. So some CIOs are listening and.

You know, how do I, how do I shore that up? Well, I'm gonna, I'll just pick two and I'll let you pick out which direction we go. But one is of course the ERPs. We didn't even talk about them, but, uh, the fact is they've been ignored for so long. I see an awful lot of activity with people investigating ERPs and now.

Coming back to pay attention to all the things that are necessary. And you know, when you look at the cost of, uh, healthcare, uh, the biggest portion of our spend is on, uh, staff. Okay, so that relates to the staffing issue. And the second biggest portion of the budget is supply chain. Uh, and that's, that's, that counts for about 90% of all the spend that goes on in a healthcare institution.

So if you're trying to look for efficiencies and, uh, efficacy, those, the, and, and trying to reduce cost. Uh, ERPs are a natural place where we should be spending some of our time pulling forward the, you know, systems that may be as much as a decade old. Uh, so I think there's a lot of opportunity there. The other thing I was gonna mention, and this is related to mergers and acquisitions, uh, and what happens afterwards and somewhat related to government system, and that is the ability of an organization to act consistently.

Across all the different components. And so I'd offer those to as places where there's opportunity for discussion and opportunity for improvements in every organization. Yeah. Uh, I, so I'm gonna pick the next topic. I could, I could go off of that for a little while, but I'm gonna pick the next topic. Keep us moving and, uh.

Here's, here's what I'm seeing. There's pressure on the IT budget. Um, there's still an education that needs to happen at the, uh, at, at the executive level, if not the board level on, um, the need for ongoing, uh, maintenance of the equipment and maintenance of the, of the tools that you've purchased. I think it's, uh, it's interesting that we're still seeing people go, Hey, we want a 4% cut from it.

And when you think about a 4% cut from it, it's, it's kind of, uh, it's almost silly to ask for a 4% cut from it because you're sitting, well, I can't cut my ER implementation because, you know, after it's done, after the capital. Um, because they're not gonna renegotiate the license. We're still using all the parts we're using.

You're not gonna renegotiate your PAC system. You're not gonna, so there's a whole bunch of fixed costs that once you buy it, they're just fixed costs and then there's cost of operating those things. And so when they say 4% to it, essentially you cut out like 70% of the budget, which you can't, they're.

Now the 4% of the total, you now have to get out of 30% of your budget, which if you do, the math is significant cut from it. And so having these conversations, why a lot of health systems. Spent the time to put things like apio in and whatnot so they can justify the spend and educate the, uh, the executive.

I'm curious, uh, are we seeing that across the board or is that just a handful of clients that I've run into? Uh, it's what I'm running into with clients and I. Think it's probably fairly common at this point. You know, the pressures on healthcare are gonna, healthcare organizations are gonna continue. Uh, and everybody's gotta hold the line and find ways to reduce costs.

So I don't think that's gonna change. Um. My, you know, I think a couple things that need to happen, you know, say CIOs are listening, what do you need to do fundamentally? Um, if, if, if you are not aligned with your executives in the board about the value of it, um, you are gonna have a uphill battle when it comes to any of these budget conversations.

And I think there's organizations unfortunately in 19 that are still in that position, though I think many are not. I think the value of it has become a lot clearer. Um, the other thing that I would say is we all, you know, everybody, it, every functional area has a, um, fiscal responsibility within the organization to, uh, be as cost effective as possible.

And you know, I know in all my years of, um. Working as ACIO and you're at the table annually and that annual budget process can take months in some organizations. And you're listening to what all other executives are asking for and, um, making your case for what you need in it. And, you know, the days of being able to pad the budget and you know, just.

Really rapid increases in growth in it budgets, um, at the expense of some other things are way gone. So you are negotiating, um, what you need with your peers. Uh, when it comes to your comment bill, about maintenance and, and that core, I mean, there's a core that you can't take away. Right. And if you can tee up for your executives, this is the baseline.

You cannot take this away. But if this is all I have, I'm not doing anything new. We're just keeping the, the trains running, the doors open, whatever you wanna say. So what you need to do is always be getting that needs to be as efficient as possible, right at the baseline. I think we all agree. Um, and you need to create the capacity for the new, the add-on and show the value of.

So, so David, we'll give you the last word on budgeting because I know you're this topic. But the, uh, I guess question a little different for you and that is, uh, should we expect health IT budgets to continue to grow and what areas within the health IT budget. Uh, minimize or reduce. Good, great question, by the way.

Agree entirely with what Sue was saying, my experience as well. Um, and by the way, I always love budgeting, so, you know, I'm one of the peculiar CIOs, but part of the reason was the governance process that we had in place aware it did not make decisions about priorities or how the money . Get spent. Uh, and instead what we did was we went to the users and said, how would you like us to spend the money you are generating the revenues that we are using?

Mm-Hmm, . So I think that was a big deal. What we came up with was, instead of using ROI because the in the net present value of every infrastructure. Uh, purchase we've made was always negative and so we could never compete if you looked at it from pure ROI or NPV standpoint. So we created what's called a value of investment, which is a much broader different view of things, and it looks at the traditional ROI than it looks at the flexibility that you get.

With the investment you make, it looks at the intangibles that are going on, and it looks at the risks of not performing or upgrading part of your infrastructure. And then finally, there's a social value, um, from a patient's perspective about what it should do. And so I think it's important to look at this ROI or budgeting radically differently.

Um, so again, making the business.

The other thing that's happening in the industry, and I, I've said this again, I think it's a little provocative, but I see the infrastructure has really reached commodity status. Um, and so rather than making it the burden of the CIO or the person responsible for the digital health strategy. To me, that's just the cost of doing business.

And to the degree that you could outsource, uh, your infrastructure, uh, then people are gonna pay for it. Then the difference is, it's like buying pizza by the slice. The more you can, you know, it is gonna be a variable cost as opposed to a fixed cost, and if you can make the leap to move it. From fixed to variable.

Now the budgeting becomes a whole different matter, and because it's, if it has reached commodity status or utility status, it's just like saying, we're not gonna air conditioning the facilities, or we're not gonna put water out through the facilities. It's, it becomes just one more utility and then we.

We're truly chief information or chief innovation officers, uh, who are helping drive the business as opposed to being driven by the business. Uh, that's, uh, again, I could go off of that. The, uh, we're teasing you very, very easily. Um, because, because the infrastructure has become commoditized, we're hearing that from, uh, a lot of the forward-leaning, uh, CIOs.

Uh, but it is provocative still amongst a significant portion of, of the group who still believes that, you know, the cloud is not secure, it's not to be trusted and so forth. And, um, you know, we'll, we'll see how that, that all plays out. I really want to thank David and Sue for taking the time to join us this week.

Uh, you're gonna have to come back next week, next Friday. For the second part of this episode, they were kind enough to gimme about an hour of their time, and we just ran through these topics and just had a good time talking to about 'em. Uh, they are so knowledgeable and articulate, uh, it's always great to have them on the show.

Special thanks for our channel sponsors, Starbridge Advisors, VMware, Galen Healthcare Pro Talent Advisors, and health lyrics for choosing to invest in developing the next generation of health leaders. Please come back every Friday for more great interviews with influencers. And don't forget, every Tuesday we take a look at the news.

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