June 5, 2020: Joining us today is Dr. Andrew Rosenberg, the CIO at Michigan Medicine. When the pandemic first hit the US, Dr. Rosenberg temporarily exchanged his CIO role for working on the frontlines and in the ICUs fighting the virus, but has since resumed him primary responsibility and has learned a great deal in the process. In terms of health IT, he discuses the sudden shift to remote work and how they are thinking about a sustainable solution, suggesting the possibly of a hybrid work model that involves both office and home time in the foreseeable future. There are, he says, certain events, tasks, and services that are best conducted in person and therefore a fully remote solution is not viable. However, the crisis has proven just how many jobs can be done from home and has had surprisingly good results, with productivity improving in some instance. Dr. Rosenberg also talks about the ups and downs of their telehealth systems, how his priorities for health IT has shifted during the crisis, and how they are reopening their services while remaining prepared to deal with a possible second surge.
Key Points From This Episode:
Field Report: Michigan Medicine
Episode 262: Transcript - June 5, 2020
This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.
[0:00:04.8] BR: Welcome to This Week in Health where we amplify great thinking to propel healthcare forward.
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.
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This episode and every episode since we started the COVID-19 series has been sponsored by Sirius Healthcare. They reached out to me to see how we might partner during this time and that’s how we’ve been able to support producing daily shows. Just a special thanks to Sirius for supporting the show’s efforts during the crisis. Now, on to today’s show.
[0:01:35.5] BR: This morning, we're joined by Andrew Rosenberg, Dr. Andrew Rosenberg, the CIO for Michigan Medicine. Good morning, Andrew. Welcome back to the show.
[0:01:43.2] AR: Good morning. Thanks for having me.
[0:01:45.1] BR: Again, thanks for taking the time. I know this remains a very busy time for everyone at Michigan Medicine. You just returned to the role of CIO after spending a few months really on the frontlines caring for patients. What have we learned in the battle against this virus so far?
[0:02:04.1] AR: I was back in the ICU for about two months. I was still doing the CIO job, it's just I turned over more the day-to-day to some other people. I think what I experienced what I learned is what you read about in the papers. Detroit area was hit pretty hard. Michigan Medicine had a lot of transfers because of that. I think our health systems, most of your listeners, we tend to do crises very well and everything I experienced was a number of remarkable examples of people coming together from pretty much all parts of the whole system, to just take care of patients and manage the crisis.
From that IT and informatics point of view though, the thing that was interesting about this one was that especially as we were trying out new things, I was one of the people using all of the new tools, or trying to use the new tools. We stood up for example, in ICU in one of our surgery recovery rooms and we were trying to bring in new types of phones and we were using some of our very early unified communication platforms, the phone we were using, the iPhone, but some of the directory and some of the patient context linking through Epic. That was the first time we were trying these things out. Everything from getting the phones and even still having a lot of people ask for physical pagers at the same time, yet we were doing a new unified communication.
It was interesting to be one of the people calling our helpdesk and asking and getting logged on and all of those things. I experienced a lot of that, plus some other things we might want to talk about.
[0:03:43.5] BR: Yeah, absolutely. Give us an idea of just some of the technology. We just started a Zoom call and you guys have implemented some new security. Are there things – in a crisis, we move very fast to stand things up, get them going. We get really creative on the clinical side. What are some things that we, I don't know, maybe experienced over the last 60 days from really reacting to the crisis to more stabilizing and preparing for a second surge?
[0:04:17.7] AR: Well, my guess is that we're like most of your other viewers. We experienced all the challenges of a very, very fast move to remote work. We all experienced not only the challenges of that, but probably many of the CIOs and other IT leaders were thinking how are we going to be sustaining this, because we knew some of the silver linings of this crisis were problems that are now eliminated, or at least significantly reduced through a lot of remote work.
An example, for us that I know is at many other health systems is the patient parking problem, the difficulty of parking in very dense areas of our health systems, now I believe has been eliminated, because much of the non-patient care, non-physical critical work, the work that can only be done in person can not only – can be, is been demonstrably working and in some cases, working even better.
From an IT perspective, what are we going to need to do to sustain that? How do we create new spaces that allow for hybrid work? A staff who typically either had an office, or a cubicle, or a set space now will not have that, but we still want and we all know as people, we do also want that physical collaborative work. Yet, there are some real efficiencies. I mean, here I am. You and I are doing this and I'm at home and you're at home and I've been working for six hours already.
I think that there are a number of areas there. The other one that's a direct correlate of that is telehealth. In our case, one of the challenges that we experience that I've heard at some other places where some of our big vendors were superb during this crisis. They made licenses free. They really look for opportunities to just help out. Others though, clearly we're taking advantage of the situation. Frankly, those – fortunately, those were much fewer.
One of our issues, for example is right now, we have at least three telehealth platforms that we could be using. Ideally, we'd like to get to one. Whether it's the integration with our EHR, or just a support remote work, I think one of the challenges that we’re all experiencing is how can we try to get to a limited number of platforms and enhance those, their feature set, their security, their ability to work in mobile platforms. That's one that I think we're all dealing with. It's probably not a bad problem to have, but that's at least one area.
The other one related to telehealth, of course, is not just how the workforce supports telehealth, but I'm thinking about those places that have already some pretty mature telehealth, they're reaping the benefits. Good for them for being out in front. We're just okay in some areas. Our ambulatory telehealth blossomed like pretty much everyone else has seen.
On the inpatient side, we don't have really rich tele-platforms, but we do have several individual ones that could be cobbled together and still be effective. The challenge I'm working on now and that's one of the things that I dealt with being in the ICU, several of us got together. We put all of them up into a couple of screens and we practiced with what would a tele-ICU for example, look like with Epic, with homegrown systems like our alert watch, with T3 that we use in our pediatric ICUs and how could we gaum together, secure web-based cameras, so that we would have essentially the feature set of a more matured tele-ICU platform? We have all the features, now we just need to figure out how to take existing systems, cobble them together, a little bit of governance and move forward with that.
Final example, just before COVID hit, we were already talking about more remote radiology viewing stations at home. We'd set up about three or six of them. Two weeks into COVID, we had 50 up and running. That's an example of a new workflow that will almost for sure be sustained, because in private practice, radiology, more radiologists are starting to work from home.
One can imagine, not just imaging, but now talk about digital pathology and other types of image-related diagnostic and care, where people will be able to start doing more and more of that from if not home, different locations. That's going to be interesting work for CIOs and other IT leaders to work on. I think we could probably come up with a couple dozens of those examples.
[0:09:28.9] BR: This is what I love about a conversation with you is you've given me, I don't know, six places to jump off of from here. I'd like to talk about telehealth, I'd like to talk about work from home. I'd like to talk about setting the priorities moving forward. Those are three things. I want to talk about second surge. I want to make sure to hit those three things. You talked about work from home, it's interesting. I mean, there are some benefits to it, right?
I mean, parking might sound – if you've worked in a hospital, you understand how bad parking is and navigation around the campus and those things. This really frees that up. Also, there's a lot of really expensive real estate that gets used in this. I think people anticipated a significant drop in productivity, moving people to their homes, but I don't think we've experienced that.
What things are you going to be looking at to determine your future model? I don't assume you're rushing to get everybody back into the office. You're going to look at certain aspects in order to determine what makes sense to come back and what makes sense to wait for another day to make a decision on it.
[0:10:38.3] AR: Yeah. One of the great quotes our deputy CIO said it a year and a half ago, Jack Kufahl, he happens to be our CISO also. We're talking about work from home. I think, maybe remote work is probably the more accurate statement, because it really is just that. We talked about productivity. I love what he said it was one of those off-the-cuff comments, but it just resonated with me very much. He said, “Well, how have we been measuring productivity to date?”
I think what it really gets to is that one, we don't really measure productivity very objectively, but we have a sense of productivity because we just see people physically around. I suppose to some extent, there is something to be said for when you're expected to dress up professionally. By the way, I am wearing clothes right now. This is not me wearing pajamas at the bottom, but when people are professionally dressed coming into the office and you walk by and in general, there's a inhibition to just be watching YouTube videos for three hours and going home, there's some degree of external constraint for productivity.
I think the more modern approach, which we were already working on within ITSM in some real sophisticated objective work with one of our other senior directors, Michael Warden, was how do we use our ITSM tooling tickets, metrics around response time, metrics around first-time solution as opposed to just taking a ticket and passing it along to three or four people? I do think that when we start looking at measures of a healthy project, measures of proper process that we can work on and improve upon, those kinds of measures allow someone to manage a more remote workforce effectively.
At the minimum, you could say to make sure you're not getting really bad, poor productivity. Ideally, that's when people start to say, “Look. Before I had a 45-minute drive to work and home. I just have an extra hour and a half of time now freed up, because I don't commute. I can be more productive.” That face validity can then be attached to other measures that we wanted to use any way around our – I'll still call it our ITSM tooling. Really, it's a much deeper view around services, metrics, measurable, quantifiable work that what I'm hearing in both talking to a lot of people, but seeing in our productivity measures, we're better.
An example, one of our very large data groups have told their senior director and they were going to be one of these groups who might have stayed at one of our old buildings as we're consolidating into one building. They said, we have no interest in moving back to the old building right now. Let's just wait until we can get into our new consolidated one building for the entire IT staff.
Interestingly around that, I was having to argue for a fifth floor in this building to move about three quarters of our IT enterprise, IT group into this new location. Now I don't have to. That fifth floor which I thought was going to be very tough to get from a financial point of view, completely take it off the table and we can move the additional 200 people into the building, because we're going to have a much more remote workforce.
What it will likely be and I'm sure others are thinking this way, it's probably not going to be that a large group of people now are completely remote. Instead, there are people who want to be coming into work, but I think it'll be a more hybrid type work. There will be people, whether it's Monday and Tuesday, it's one team and Thursday and Friday, it's another, or a lot more hoteling space and a lot more collaborative space. There will be some formal, these are days where teams come together for team meetings, team work, joint sessions. Then there's going to be a lot more work from remote. I think that overall milieu will overall be a more productive and frankly, collaborative milieu for us to work in.
[0:15:05.7] BR: Interesting. All right, so you touched on some of this around telehealth. We've seen significant gains, obviously virtual visits in the ambulatory setting. Everyone's touting their numbers, went from 500 visits to 5,000, or even more than that. In some cases, we've seen a tenfold increase in virtual visits. You start talking about some of the other things, which I think are important. Our remote ICU, remote patient monitoring, things that can keep people maybe at home and provide a better level of care and monitor them.
We use chatbots pretty extensively during this as well. What do you think is going to be the long-term impact of having experienced this pandemic and put these technologies really as intermediaries in a lot of cases, or as mechanisms to provide care in different venues? What do you think the long-term impact of the pandemic is going to be on future work models?
[0:16:10.8] AR: Well, I think the one that will most talk about, the one that will get the most money behind it will be all manner of telehealth. We talked about it before COVID. We discussed it from a variety of angles that all made sense, of patient engagement, patient satisfaction, efficiencies of a healthcare system. Like you mentioned, care at home, something that we've been working on with some of our large payer partners to start coming up with mechanisms for true inpatient type care now being delivered at home. All those things I think are only going to continue to expand.
They had a great interest before COVID. They needed an activation energy, to borrow an old chemistry term. That activation energy was that catalyst actually to overcome the activation energy was COVID. I don't think we're going back in that. The long-term engine of that will be the financing of telehealth, both professionally, but even from a facility's point of view. I do think some of the benefits are going to be clear to people. I think some of the downsides might be though, the potential further centralization of healthcare, because of the large health systems being able to afford the infrastructures to do this.
I don't know what it means to the smaller vital healthcare providers. I don't know what it means to the non-large medical healthcare providers. What does it means to long-term care homes and therapy and mental health and some other areas? Although, mental health is a good example of one of the more amenable to telehealth programs. My brother's chair of psychiatry at Wayne State and he said ironically, that during COVID, his department may be the only one that has not seen a significant financial loss, because they've been able to do most of their work virtually and in some ways, it's even more effective to get some of these types of services out into the community, into rural areas where they're less common.
I do think though that the area that we’re likely to see a variety of different work will be again, the non-healthcare related remote work. I'm spending probably as much time thinking about that and all of its efficiencies. An example you said was we have some very new buildings and we have some very old buildings. The old buildings have always been an issue, because they require a lot more maintenance. We felt we needed them. They typically are where a lot more administrative work is done. To me, that's a win-win, where we can start to very quickly move away from higher cost areas and use a lot more technical means to support remote work.
There are very few people who desperately wanted to stay in old buildings that cost a lot to maintain them and commute from long distances, as opposed to for example, our hospitals and our clinics. I do think that there will be new services and new ways of working that will be fundamentally changing to society. We're seeing it in education, both good, but also very bad.
I've seen a real mixture in how both what we have been needing to support for our medical school, for the most part good. A fact that there's senior classes having to graduate on Zoom, no one wants to do that. Colloquiums and other meetings where people benefit from all of the pre-meeting and post-meeting discussions and that quick ability to talk to each other and to manage things, no one really wants to only do that remotely, let alone thinking about how are we going to start the next school year for our medical students and our graduate students and our nursing students, let alone being part of the university. That's an example where remote is not ideal. In some cases, it is. In other cases, it's the exact opposite of ideal.
I see us having a much more interesting conversations in some ways around the non-telehealth remote work and what are new tools. You mentioned chatbots. Yesterday, we had one of our largest network outages, in fact, probably the largest network outage we've ever had. I had to deal with that for about 12 hours. It took about 24 hours. It was a power source in one of our data center. It was a maintenance on power and we still don't quite know why, but all circuits shut off and we had a full stop of a scale we've never had before.
The impact was that much greater, because of how many people now are working remotely. One of the interesting correlates of all this remote work is we're even more dependent now on IT, on our networks, on our numerous services. One of those examples that helped out when our call distribution phone platform went out was our chatbots and our ability for people to still – not our bots necessarily, but people to still use chat to get to our service desk.
Cellular as a backup spectrum became incredibly important and I think we'll see that really blossom as we get into not just more and more unified communications, more cellular-related, but certainly as 5G starts to trickle in and emerge, we'll see even more applications running off of that spectrum. Now that we're more distributed, now that we're that much more dependent on this work, where will we see some acceleration in those areas? Those to me are interesting questions.
[0:22:27.2] BR: Yeah. This is a fantastic conversation. We're going to end up going a little long and I'm just going to keep going, because I do want to hit on priorities, how we're going to set priorities. I do want to talk about a potential second surge and where we're going. I'm going to give the date that we're recording.
This so we'll probably not go live until next week, but it's May 28th we're recording this show, 2020. How are you thinking about your priorities for health IT? You had a set of priorities coming into the pandemic that were well thought out, that went through governance, a lot of people talked about. Now you have maybe not a whole new set of priorities, but you have some things that have popped up as a result of the pandemic. How are you going to prioritize the work? How are you going to evaluate all the things that are coming at you at this point?
[0:23:19.9] AR: Well, I laughed at that, because I think like most people, one of the tough parts of COVID is that we're all going through cost-cutting. I'm as much trying to shift that as much as I can to cost optimization type discussions, not just cost-cutting. Those tend to be one-time. They tend to be disruptive. We tend to get over it and then yet, we haven't really dealt with the underlying issue.
My laugh at your question was that all of my priorities before COVID essentially got just completely wiped clean. During COVID and now coming out of it, our priorities are focusing on what really is core to the mission. It's a tough conversation, because most institutions have a lot of trouble really prioritizing all the what must be done, what's core versus what's nice to have. We’re probably as good and as bad as many other good institutions.
From my point of view, what it has done is it's helping me articulate what really is core to our mission just a little bit more. I've mentioned a few of the examples already. Where we're duplicating, where we have three telehealth video platforms, things like that. I'm hoping that this will give us a little bit more clarity to point out what really is core and what we have to focus in on. That's driving most of our budget discussions right now.
The challenge for me and it might just be somewhat local is our dependency on technology has never been greater. Yet, getting more choices, more priority towards technology and IT and data and information services and less from manual work, that's still a slow process. An example is doubling, tripling down on our PA type efforts that we had already started, robotic process automation and frankly, other automating processes. I'm spending a lot of time trying to point that out as a value, not just to get through the budget crisis of COVID, but really set us up into new work going forward.
The final piece to what you also said is trying to think about some of our priorities, whether it's surges in COVID, or other disruptions. It's what of the things that we did during COVID can we really demonstrate made us more nimble. We can point to a good half dozen to a dozen of those. Those are the things that were very, very clearly emphasizing as we go forward. One of them are the tooling that we've done that allowed our staff to work very effectively remotely and make sure that that only gets more attention and effort.
[0:26:14.6] BR: It’s interesting. When you say budget crisis in healthcare, for those of our listeners who said, “What budget crisis?” I would just encourage you to go listen to, we had Rob DeMichiei, the former CFO for UPMC on the show and he explained it in detail. Just if you're not familiar with what's going on, we essentially had the surge. We shut down elective procedures. Then essentially in a lot of areas that the beds did not fill up with COVID patients and it created a significant financial gap.
We're not going to cover that. What I'd like to do is we're seeing signs that just from claims data and other things that are going on from conversations I'm having, health systems are starting to take those procedures back. We're starting to see a increase in electric procedures, which is good. That's the financial health of the of the organization. It's important we are seeing upwards of 85% capacity now, even pushing 90% of capacity, which is great. As we do that, my two-part question here is how are we going to do that safely? Then the second is how are returning to that work, while also keeping an eye on a potential second surge?
[0:27:33.4] AR: Well, I think again probably, we’re like many, we had had these ideas around 24/7 hospitals and significant more efficiency. One of the silver linings for us is that as we had built some more capacity over the last few years, we weren't using it really as efficiently as we could. Particularly in some of our ambulatory areas now, we're reopening our ambulatory sites with full efficiency. Only when we've achieved that, do we then open up further sites. That probably will allow us to sustain a lower cost per unit service, which we've been trying to do before COVID.
I would suspect other viewers are finding those opportunities. If not, that's something that we're doing actually very well. I think it gets broad support. As opposed to our hospital, which like others, we were running at 97% capacity, almost inefficiently full. Now we actually might be able to find some mechanism, plus some of our new analytics to try to just take a bit of that edge off and stay more efficient. For example, to accept more transfers, to shorten wait times for patients.
I think there's some silver linings in terms of capacity, bed management, transfer management that this crisis if we emerge out of it effectively, may help. A similar example that I mentioned before around the 24/7 hospital, while we're not running 24/7, we have expanded services into Saturday and somewhat later hours. I think maybe, people just want to be getting back to work and feeling secure in their work. I don't know how long it will sustain. If we do it properly, we might sustain it and that should take down some of those longer wait times and engagement.
Those are examples of silver linings that I hope we maintain after the crisis. That will also with some of the technology points I made before, allow us to not close down as completely as we did before. Better screening, of course, is absolutely critical than anything we talked about at all. Better identification, we've worked with our EHRs, I'm sure others have to do a much better collation of data, so that a more accurate signal that a patient either has high-risk, or had COVID will allow us to maintain operations, as opposed to shut everything down and only be a COVID hospital.
I think those are the kinds of things that we're going to see during the emergence, during any types of surges and spikes, because I don't think the economy is going to allow us to shut down as much as we did before. It's also, I think going to help us for some next future items, whether they're infectious diseases, or other surges and be able to manage those more robustly in the future as well.
[0:30:35.5] BR: All right, the million-dollar question. My daughter goes to Baylor and she has been studying this semester obviously from home. One of the reasons you choose to send a student to Michigan, or Baylor is that experience, I guess. As we look to the fall, this is my closing question, so that there's part of this that's I'm just curious. Are we going to see football in the fall? Are we going to see college campuses open? I mean, do you think that's going to happen?
[0:31:03.5] AR: Well, my daughter's a freshman at Michigan and she’s a music theater. It's difficult to do music theater, all the acting and the dancing remotely. It's been very, very tough on that small and elite class. I, like you, feel this very viscerally. My best guess is that schools that have not announced that they're not going to open in the fall. Those schools that I think are still trying to stay open will try to figure out a way to stay open.
It's going to be very, very difficult from the dorms and the eating halls, to the large classrooms. It's not just for the students, it’s for the faculty. I can't imagine how large football stadiums would be able to handle those kinds of crowds. My best guess is that schools will try to reopen with public health supported practices, but that the large sport venues, particularly football, will not go forward this fall, which is very tough for so many people, not to mention the athletes especially in their senior year. But what else do I know? I have no other insight for that.
[0:32:25.6] BR: Yeah. I mean, we're just speculating at this point. Andrew, again, thank you for your time. I really appreciate you sharing your experience with the community. It's always appreciated.
[0:32:35.5] AR: Absolutely. Thank you.
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