The trends for this year are emerging and Social Determinants and Consumer-Centric Health are two widely talked about items for 2019. David Bensema, M.D. and I discuss where the emphasis for Health IT should be for these two important discussions. Hope you enjoy.
Bill Russell: 00:06 Welcome to this week in health it where we discuss the news information and emerging thought was leaders from across the health care industry. My name is Bill Russell recovering healthcare CIO and creator of this week in health it a set of podcasts and videos dedicated to developing the next generation of health leaders today a little back and forth on industry health it priorities. This podcast is brought to you by health lyrics. Want to start your health it project on the right track or want to turn around a failing project. Let's talk visit health lyrics .com to schedule your free consultation. Our guest today is a retired healthcare CIO and physician and a good friend of the show, Dr. David Bensema. Good Morning David. Welcome to the show.
David Bensema : 00:43 Good Morning Bill. Thanks for having me.
Bill Russell: 00:45 You know, we usually start with a softball question of, you know, what are you working on it? And I will get to that in a minute, but you know, you shared with me, uh, yesterday, uh, woodworking projects that you're working on. Do you mind talking about that a little bit?
David Bensema : 00:59 Yeah, one of the great things about not having a strict schedule, I'm able to do some more woodworking, but I have four grandsons and so they dictate a large portion of what I do. My five and a half year old has been obsessed with the titanic for the last two and a half years. In fact, he was John Smith for Halloween last year, Captain John Smith. And so he asked me to make a wooden replica of the titanic. He had seen the replica of the Disney magic that I've made for his cousin. And so now he wants us, so I'm hollowing out a large walnut timber to make the hull and we'll start building the lower decks, uh, later this week.
Bill Russell: 01:39 Obvious questions are a five year old become obsessed with the titanic. I guess that's the first. How does that happen?
David Bensema : 01:48 Yeah, so he, he saw a book, um, in the store that had titanic on the cover. He decided he liked the look of the ship and he started having his mom read him Things about titanic. There are things you leave out when a child is three and a half to five and a half and so there's not a lot of discussion about the loss of life, but there's a lot of discussion about how it was the most modern ship of its era. And so he has done a little Lego type block replica of the titanic. He has built cardboard replica, my basement is strewn with cardboard from his efforts and just stays with it. It's, he's an interesting little guy. He's, he's my a mechanical genius kid.
Bill Russell: 02:33 Wow. I guess the following question is, Do you have to be a grandkid to place an order for one of these ships? Imagine the answer is yes.
David Bensema : 02:44 Well, if you're not one of the grandkids, you get way to the back of the line and the line is long
Bill Russell: 02:52 how are you keeping up on what's going on in health care? I mean there's, there is or are there things you're still involved?
David Bensema : 03:00 Yeah, I'm still very actively involved with the State Medical Association and with the American Medical Association. I'm a delegate to the American Medical Association and one of the areas they look to me for is my experience in health it. So that causes me to want to keep reading. And I'm, one of the other great ironies is I have more time to read now than I have in my entire career. So I probably read two to two and a half hours a day in the industry and then do some pleasure reading of right now I'm reading a book loathing Lincoln that was written by one of my old track teammates. And it's about the way over the years that people have chosen to manipulate the Light Lincoln legacy, uh, whether conservative or liberal, et cetera. Um, it's always been an interesting thing how we twist things, but I have a lot of time to read. I'm enjoying it.
Bill Russell: 03:53 Imagine that would be an interesting dive. So it's, it's been, it's been a while since I've had you on the show and I wanted to catch up with you on the priorities and emphasis that we're seeing in the first half of 2019 from health care. And, uh, you know, two of the things that we've sort of talked about ahead of the show to discuss, one is social determinants of health and the other is consumer centric care. And, uh, I, I'm going to let you kick it off. So I want to let you kick it off with, let's start with social determinants because that was a huge topic at JP Morgan. It was a huge emphasis at the HIMSS conference and I think a lot of help it people are saying, okay, you know, I mean, you've been collecting these, these, I don't think people realize this. We've been collecting social determinants data in the Emr for years, I mean in nursing notes and those kinds of things. So, um, what else do we need to do? I mean, what's, what's the, all of a sudden that the mass emphasis and how are we going to get our arms around it and make it digestable? I guess,
David Bensema : 04:59 yeah. So one of my concerns is it has been around for years, but, uh, who the World Health Organization has talked about social determinants for many, many years. And we know on a macro level that if you look at populations and you determine, um, how they fit into these 11 domains of social determinants of health, you can show evidence that people do better when they're in certain categories and worse when they're in certain categories. But now we're asking primary care physicians or point of care clinicians to capture these 11 domains in a more formalized way because we want to be able to do the data dive and we're burying the people who are already buried. Um, so my concern is it's a great catch phrase. Everyone talks about it. It's kind of like population health has been, we love to talk about it. There's a whole bunch of people making money talking about it, but no one's really solving it.
David Bensema : 05:56 I think the American Academy of family practice has probably done the best job in determining how do we get it into the workflow and creating, um, a conceptual framework for how we bring it into the workflow. But my personal opinion is that the data gathering is going to have to be through a patient facing interface registration process much like they do for their pre visit, um, registration in my chart or other patient portals. And then we have a chance of using background diagnostics, background analytics to present opportunities to the care team at the point of care. But if we expect it to be done by the care team and created by the care team, it's not going to happen. We're basically asking people to do what the Census Bureau cannot even do. We do a sampling as the Census Bureau and now we're turning to the care team. When we're saying do 100% do every single patient who comes in, every single American, every single person seeking care in these areas that are really census bureau type data, how do we make that work better? The AFP I think is on the right track, but we don't even have research that shows that on a microcosm level we can impact health by knowing these social determinants. We know, we know what a macro, we don't on a micro.
Bill Russell: 07:28 All right, so I would put you back, you're going to be the CIO for, for a health system that you were in Kentucky, so lets put you in Chicago. Social determinants in Chicago would be a, well I'm sure it is in Kentucky as well, but let's take you to Chicago. Um, because you know there are, there are, uh, let's see there, there are documented cases where, you know, zip code really matters and you can literally live across the street and have completely different outcomes. So it's a lot of nonmedical. So that's why social determinants is sort of escalated and its and its importance our, yes, right now plus the push for population health. Um, so I make you a CIO and I say, all right, the physician community is looking at us saying too much data. I mean you're already asking me to see a patient in 15 minutes and those 15 minutes that I don't have enough time to go through all this data and have a meaningful dialogue with the patient about. And 15 minutes in some in Chicago might be kind. I mean, it might be eight minutes or something to that effect. Um, so, uh, they're going to look to you, they're going to look to you, the CIO and say, you know, take all this data and we're now connected. We're getting housing data, we're getting education. They were getting all this data. I want you to make meaning of it, but where do you start?
David Bensema : 08:53 So I think the first place you start is with much better analytics than we currently have been applying and analytics sets in the background and then presents prioritizations and succinct opportunities to the clinician and not more than three at a time. Um, and it's Kinda like what I've talked about with um, uh, the alerts. I don't want a ton of alerts, keep it to a limited list. I'll work through them. If, once I've addressed something, it goes into the system and it knows not to bring that alert to me. Again, same with these opportunities and social determinants. My team and I as a primary care physician can work on the two to three and once we get them off the list, new ones come up. Um, so better analytics in the background, a more seamless presentation to the physicians in the workflow. And then the big thing is it cannot be on the primary care physician or the specialist to implement a lot of the interventions.
David Bensema : 10:02 A lot of them are social interventions, public health interventions, societal obligations. So we can as physicians make the patients aware that they have these opportunities and point them in the direction. But our nation, our system has to do a better job of providing those resources and making sure they're responsive to the needs of the patient. So it, but it starts with the analytics. Um, and it, again, as I said earlier, it starts with the capture of the information which is going to have to be largely from the patients recognizing that we have a percentage of the population that is not literate and is going to need assistance. But the vast majority of us can enter the basic information about ourselves, those demographic and uh, address type information.
Bill Russell: 10:54 It's interesting because one of the areas is really, it gets highlighted in an urban setting is in the er, because you have a lot of people present in the Er who quite frankly, it's a result of neglect over time of addressing some of those core social determinants. And one of the things our physicians were asking for was it, it's too hard to find all this data within the EHR. Now we can argue, which EHR is better at that or whatnot. But none of them are great at it. And so what they were asking for was an overlay. They're asking for something where they could get a quick snapchat. And obviously behind that is a whole bunch of integration so that you can pull that data out of the EHR. A whole bunch of, uh, analytics, be it predictive or a retrospective analytics, be it machine learning or AI, the buzzwords on top of it.
Bill Russell: 11:54 But regardless, it's all analytics. And then you're presenting that in almost like a, a red, red, green, yellow kind of thing. So they can look at it and say, uh, you know, there's a housing issue and single click like, okay, I'm going to make a, uh, just like you're prescribing medicine. You're like, I'm prescribing housing and urban development to help you out, whoever it is, whatever the agency. But it has to be fast and it has to be simple. It can't be the doctor sitting down and saying, Hey, let's talk about your housing situation. Oh, you don't have air conditioning. I, that's, that's not really going to be their role probably I wouldn't think.
David Bensema : 12:35 Right. But I think you're right. It needs to be presented in a, again, in the workflow, much as we do with opportunities for immunization, opportunities for screening exams in the system that I was with Baptist health, they're now using the Ehr to present to the physician at the time they open the patients chart those opportunities and it's presented to their medical assistant and there's opportunities where those can be ordered by the medical assistant to be confirmed by the physician. We're trying to simplify doing the right thing and we've seen our screening rates go up since the implementation of the integrated EHR and providing that we need to do the same with the social determinants. Not expecting the physician himself or herself necessarily to address those, but their awareness and they're pointing the team to say, what can we do or where should we refer that can be done by the whole care team.
David Bensema : 13:35 That can be done at the discharge desk by clicking on a couple of those social determinants. It then tells the discharge person, make sure they have an appointment with a social worker, make sure they have, um, the address and a contact at food bank, make sure they have, you know, whatever. Um, uh, contact at the gas company so that they don't get their gas shutoff, they have heat. Those things can be done in the workflow. We just have to present them better in the dashboards and make it be as simple as one click. Um, anything more complicated, it's not going to happen. I did primary care for 16 years and I was overwhelmed in 2006 as I was finishing up my primary care. I can't imagine being my colleagues now.
Bill Russell: 14:25 We have to make meaning of the data. There's going to be more data than ever. That's the role of the CIO. Chief information officer. Do something with that. So you reference a framework that has the 11 categories. What's the reference for that?
David Bensema : 14:40 The reference is the perspectives in primary care. It's a 2016 study by the um, or editorial by the American Academy of family practice. It's in their journal. Um, and uh, let me see if I can quickly give you the actual date. Um, it's annals of family medicine 2016:14:1043108 Okay. So, so as volume 14 of the American Family Medicine journal.
Bill Russell: 15:18 All right, so social determines of health. Here's the thing I like about this conversation is we were, we were talking about interoperability almost the same way. We're talking about this now maybe five or six years ago. It was a huge hype at Himss chime. We were talking about interoperability if you went there this year, interoperability was, it was a huge focus, but it was more showcasing a, just a ton of solutions around interoperability. And we've, uh, we haven't tackled this problem to the ground, but there's been so much momentum on it that you're starting to see solutions rather than, um, people sort of throwing their hands up saying, well, you can't do interoperability in healthcare. And I think the same thing's going to be true here. It, you know, you have this escalation phase where everyone's talking about it and uh, and the community's going to go about solving this problem. And I think in two to three years, um, you know, we'll have a new problem to solve, but social determinants will be something that we have a, hopefully wrestled to the ground in a few years. Um, that's, that's my hope.
David Bensema : 16:20 Yeah. I think from a knowledge base, and any presentation base, I think you're going to be right. I think from the real solutions, that's a huge social lift that's well beyond you. And I am the it world.
Bill Russell: 16:33 Well it, you know, it's not a medical right. So way beyond health care as well. I mean there's, there's so many uh, institutions and agencies we've got to figure out, um, data sharing across that we've got to figure out referrals across that. Uh, so we're creating all sorts of new patterns within healthcare and it's good and it's just going to take some time. Yep. So consumer centric care, um, you brought this one up. I'd love for you to tee this one up.
David Bensema : 17:00 Yeah. So consumer centric care is another one of the catch phrases of the last year and a half. Um, and when I hear it as a primary care physician, CIO, I hear it thinking it cannot be consumer because patients come different than a consumer. If I walk into my local appliance store or my local, um, auto dealership, then I'm a truly a consumer. I'm able to be informed about the product. I mean, with my money, I know how the interchange is going to happen. I pretty much controll a large portion of that interaction and most important thing, I don't need either of those. I may want those things, but I don't need them. So I can walk as a patient, I need care and I come fearfull and I don't really understand the pricing. Even with um, posting, uh, the chargemasters, I still have no clue what the pricing is for hospital care and no immediate ability to fully understand that no one's going to immediately understand all the abbreviations of codes.
David Bensema : 18:04 Uh, uh, even if you put it out as DRGs, you know, it's, it's just hard for the, the patient really understand that and particularly in a moment of stress. So I kind of rebelled against the consumer centric. I think we need to think more how do we care for people holistically and in a way that does work to delight them. I mean, the consumer catch phrase of a couple of years ago, it was delight. You know, anything I present to people should delight them. Oh, I always thought that way about my practice. I always wanted a patient leaving, anxious to tell five more friends, you need to go see Dr Bensema. And if you approach it with that attitude, then you are always going to be focused on the patient. Now that doesn't mean you give them everything they want. It means you explain your rationale and you engage them and then partner with them in that care. But to call it consumer centric, I just think is a misnomer.
Bill Russell: 19:05 Yeah, it's interesting you brought that up. I haven't really thought about it in a while, but when we were developing our models around this six or seven years ago, um, we, uh, we always kept consumer and patient separate. And the reason we kept him set, we had, one of the things we identified was there was a 1.5 million people in Orange County that we didn't see and we just call them consumers. They didn't have a medical record. We didn't see them. And we said, well, we still have to care for them. What category do we put them in? well they are consumers of health. But they're not a patient. So let's just call them consumers. But we had a clear delineation that once they came through the door, they became a patient. So there were, there was, there's different, there's different strategies, there's different technologies, there's different approaches to how you care for somebody who's not a patient versus how you care for somebody when they become a patient.
Bill Russell: 20:01 And a whole. Not a whole new set of tools, but a lot of the tools are very different. Um, you know, you go from, hey, we're measuring stuff on an apple watch over here too. Hey, we're actually going to connect them to an EKG or ECG over here. I mean, the tools are different. The, the technology is different. How you're measuring it over here and it's super world and a database that's outside the Emr, but once they step through the door, now all of a sudden you're trying to push as much of that data into the Emr because that's into the workflow. So we tried to keep those two things to sustinct, but I can understand, I understand where you're coming from in that if, if that's not, if there's not a clear delineation and we're trying to treat people as consumers after they walked in the door, um, maybe from their perspective they have a choice and you want to, you want them to be happy, that's great. But doctors have to say some hard things. People aren't always going to walk out happy.
David Bensema : 21:00 We used to talk to our system about the fact that the consumer centric was the marketing aspect. It's how do you get a community presence? How do you make awareness in the community and trust in the community? How do you develop that? Whether it's through Facebook, tweets, a newsprint, all those things that marketing does is to create this element of trust. My job once the patient comes in is to focus wholly on that patient so that I fulfill the promise that was created by the marketing. But I'm taking care of the patient. And my concern is that we've talked a lot and I think there is value to bringing some folks from outside the health care industry, but they've got to be strongly supported by a team of deep healthcare experience who's then open to innovation, open to new ways of approaching things. But you can't just turn it over to somebody from outside the industry because they've had success somewhere else in the consumer facing aspect of their industry. They, they're not going to understand the nuances of healthcare. They're not going to understand the, um, the incredible responsibility of that trust relationship that begins the moment the patient starts to register. And once that patient has chosen to receive their care in your system or I didn't, you know, the showing up in your Ed to receive care in your system, that patient becomes a wholly trust or your system. Yeah,
Bill Russell: 22:32 absolutely. So let me, let me talk to you. So there's an article released today, which will tell you when we're recording this show, even though it's going to be released on Friday, but cardiologists say apple is overselling. It's health rollout as FDA applauds and it talks about how Apple's touting their, uh, their watch as a detection system for a fib. Critics are concerned that the FDA's unusual celebration of Apple's new technology, uh, which was central to apples roll out the concerns center around the algorithm, accessible through the Apple Watch, which detects a fib and irregular heart rhythm that can elevate some individual's risk for stroke. In many cases, the watch has given a user's warnings and that led them to get a necessary and even lifesaving medical health. And it goes on and had been sites of nurse whose daughter had kidney failure.
Bill Russell: 23:22 And the Apple Watch predicted something that they didn't see. Um, and it it in CNBC, you know, you know, users are telling me they found a problem with their heart they didn't even know existed. And if they wouldn't have reached out to a doctor and they might've died, these are life changing things. Cook said Cook, who's the CEO of Apple? But doctors are worried that when used by millions, the a fib warnings could lead to unnecessary even harmful medical care. That's why Apple's marketing of the success stories bother them. And it goes on to talk specifically about cardiologists are concerned. Many people using Apple Watch might respond to detection of a fib by unnecessarily seeking treatment to date. The benefits of treating the condition have been proven only in certain at risk population such as elderly and hypertensive and diabetic. Um, it's interesting because this post, I saw this on Linkedin this morning and uh, the people who commented on it, we're all physicians and it was all, see this doesn't work.
Bill Russell: 24:26 See, you know, you know, there's no, uh, there's, there's no research studies. There's no, there's no proof that this is going to work. Um, but from somebody who, a technologist and somebody who's actually wearing an apple watch, and I see the benefits to the consumer, I understand that once they become a patient, I'm not going to prescribe an apple watch and say, Hey, this is how we're going to monitor your health. It's not there yet. The consumer world, I would think it, it's a, it's a decent thing to have that little thing say, hey, you might have afib, call somebody and talk to them.
David Bensema : 25:04 Yeah. Yeah. So my take is number one, apple has done a more thoughtful job than a lot of the APP developers. A lot of the folks that, you know, there's, there's a lot of trash out there and we're aware of it and we want it to be cleaned up. But I'm also aware that anything that increases societal awareness of their health and improves their focus on preventive health or um, altering their health status and their health risk profile, I'm all for it. And so the Apple Watch has some potential benefit there. I don't care for practicing anecdotal medicine. So the testimonials are always, I'm leery of it. And some of my physician colleagues, I understand they're kind of backlash against that and I understand the need for studies, but I also understand that getting a patient in who's concerned, cause my apple watch told me I have a fib also gives me as a primary care physician the chance to talk to them about.
David Bensema : 26:04 Yeah. And you're 35 pounds overweight and you're really more at risk for type two diabetes and you probably have prediabetes. Let's work on that and probably as I get you to do more exercise, this question of whether you have a fib or not will resolve itself. Now having said I don't like antidotes on an Ekg, I can get the algorithm to read me as a fib simply because my resting heart rate is 42 and I have a respiratory variation so I'll drop as low as 26 and go up to 50 and in doing that I have irregular spacing of my QRS, which is the little spiky part of the EKG and algorithm reads me as being in a fib when I am in total sinus Bradycardia induced by my lifelong running habit. So I, you know, that's the risk, but you know, let's talk about it. Patients who for the most part are going to be able to understand if I take the time to explain that to them.
Bill Russell: 27:04 Yeah, I mean my initial, they're seeing doctors and they're saying, hey, they're asking for unnecessary tests as the doctor. I mean, your thing is to say, you know, we can do the test if you're concerned about these things. But let me, let me explain to you what a fib is. Let me explain to him where it comes from. I just don't, I don't see the downside
David Bensema : 27:26 as, as a physician, my job is discerning as the patient. You're job is to get in when you have a concern.
Bill Russell: 27:32 Here's where I think the doctors have a, have a really good point, which is the analytics, the analytics have become a black box, you know, so what's it, what's it reading behind the scenes and then spitting out results to, to a patient and saying, hey, you might have x, you might have y. And, um, this is the area that I think we're going to see a lot more pressure on these tech companies and especially the data companies. The, the Amazon wants to get in a Google's, I mean they are in Google and Amazon are in Microsoft and you're going to see a lot more pressure I think on really exposing what the algorithms are looking at and, and uh, submitting those to, uh, uh, really to some, some academic rigor around or, you know, are these accurate? Are they actually predicting what we think they're predicting because people are going to start making, people can make mistakes. So can algorithms and having them be behind the scenes and it's like, hey, don't worry. We trust Google. They're going to give us good stuff. No, no, I understand some of that. Your proprietary information. But, um, if you're going to be treating people that comes under the FDA, that'd be, if you're going to be making recommendations and it comes a medical device, they skirt that, close it by saying, well, we're just making a recommendation to the doctor. But either way, uh, I think we're going to see a push to,
David Bensema : 28:58 yeah, they even call it just creating an awareness as opposed to the recommendation.
Bill Russell: 29:03 Yeah. It's interesting. If I were bringing these tools into healthcare today, one of the things I would probably would require is, all right, I, you know, I don't want you to, I'm not going to put me under Nda, but we need to be able to look at your algorithms. We need to be able to look at how, how are you generating that green light? How are you generating that red light? And sure.
David Bensema : 29:24 And at the same time that we're talking about Google and apple and others coming under that type of scrutiny, and I'm not totally agree, we need to do the same as a medical profession with our care guidelines because so many of them are really just a rehashing of what has been historic care community care standard. But that doesn't necessarily mean it's evidenced based. We need to subject our care guidelines to evidence-based good research, just as we're going to ask them to submit their algorithms to good validation research. Then our patients benefit. I mean the bottom line always, and you've heard me to do this before, I always come back. You know what's best for the patient. It's not a matter of you know, me getting to do my procedure because that's what I do. You know a man with a hammer is going to pound nails or me getting to make money or me getting to stand in front of my shareholders and say here's the dividend in here.
David Bensema : 30:23 You know we we supplied was dividend. It has to be what's best for the patient and we just have to always come back to that as our core conversation. I did that as the CIO with my team. I said each of you is as much a part of the care team as the clinician at the bedside and you always have to think about how am I impacting, how am I benefiting the patient and the team finds inspiration in that and I think our it colleagues find inspiration in recognizing that that's who they are, but we across the industry have to keep the patient first in our mind back to the consumer centric to patient center. Patient has to be the reason you're doing it. Yeah, absolutely.
Bill Russell: 31:05 David as always a great conversation. I guess the next time we'll see each other is, is in the desert at the Scottsdale Institute and uh, very much looking forward to that. Yeah, I'm looking forward to it as well. And we will get out on the golf course and show each other how little we have played and practiced Our Golf Games should be fun. It'll be very fun. This show is a production of this week in health it for more great content and you check out the website at www.thisweekinhealthit.com or the youtube channel @thisweekinhealthit.com/video. Uh, thanks for listening. That's all for now