April 29, 2020: This episode is the recording of a live stream we hosted at the end of April, for which we welcomed Sue Schade, Drex DeFord and David Muntz for a roundtable discussion on what Health IT might look like after the COVID-19 pandemic. We start our chat sharing impressive action we have each witnessed during this crisis as well as the biggest challenges we see moving forward. The lasting financial implication of the crisis and the importance of data collection and systematic adjustment are underlined. From there, we consider what the often spoken about 'new normal' might look like and how organizations should approach prioritizing things after COVID. We cover privacy and staffing concerns before delving into the issue of interoperability and imagining a future with a better digital record system. Each of our discussants share some particular insight into areas of interest, showing just how complex this situation is and will be. We find ourselves at a daunting precipice, yet one that offers opportunities that might not have been imaginable without the difficulties we have faced as a health sector and society. We finish off this live chat fielding some questions on cybersecurity and leadership in a healthcare space, so join us for this incredibly insightful broadcast!
Key Points From This Episode:
LiveStream: Exploring a Post COVID Health IT
Episode 237: Transcript - April 29, 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.
[0:00:00.8] DM: It’s the best shot I got at helpdesk.
[0:00:11.9] SS: I think you’re good. It’s showing live.
[0:00:15.9] BR: It’s showing live. Live on YouTube. It says that on the upper left-hand corner.
[0:00:19.9] SS: There’s a message. Meeting is now streaming live on YouTube, though.
[0:00:23.3] BR: Yeah. Yeah.
[0:00:26.6] SS: Still streaming live on YouTube now.
[0:00:28.7] BR: All right. We hear your echo. Wow. Let’s do this. Okay. Can you guys hear me still?
[0:00:42.9] DD: Yes.
[0:00:45.6] BR: Fantastic. It’s great to have you guys here to be moral support for me, to make fun of me as the technology did not work. That is all very helpful.
[0:00:59.9] DD: That’s what we’re here for, buddy.
[0:01:01.1] BR: That’s what we’re here for. All right, first time, we’ll see. If anybody on the chat is having trouble hearing or anything like that, please just let me know. I'm going to kick it off here. It's noon. It's time to go.
Welcome to This Week in Health IT Live. This is episode 237. Hard to believe. My name is Bill Russell, healthcare, CIO coach, creator of This Week in Health IT, a set of podcasts, videos, collaboration events dedicated to developing the next generation of health leaders.
This episode and every episode since we started the COVID-19 series has been sponsored by Sirius Healthcare. Special thanks to Sirius for supporting the show's effort during the crisis. Thanks as well to our channel sponsors, VMware, Galen Healthcare, StarBridge Advisors, Pro Talent Advisors and Sirius Healthcare for choosing to invest in the next generation of health leaders.
All right, are you ready for this? I am certainly ready for this. I'm excited to do our first live show with three friends of the community; Drex DeFord with Drexio Innovation Network and CI Security, Sue Schade and David Muntz, highly decorated veterans and principals at Starbridge Advisors. Good morning, everybody. How's it going?
[0:02:10.3] SS: Good morning.
[0:02:10.4] DD: Good morning. Great.
[0:02:11.6] DM: Good morning.
[0:02:13.5] BR: First comment we have is that Drex needs a haircut.
[0:02:18.1] DD: That’s right. That sounds right.
[0:02:21.6] SS: Bill, I want to put you at ease for a second. Just as you were starting a truck pulled up. I heard it deliver, the doorbell range, the dog barked. I went to mute, so it wouldn’t interrupt you. That’s all of our –
[0:02:36.0] BR: This is live.
[0:02:36.8] SS: Right.
[0:02:38.5] BR: That is the essence of a live show, right there. I'm really looking forward to this conversation. Part of me is nervous, but I'm through the worst part of it, which is I think technically we have it live on YouTube. I'm going to set the stage and for how I think this is going to go and just like everything else we've ever done on the show, we're going to try something out and see how it works and we'll move forward from there. Before we get going, I think it's important to note that this is a forward-looking show. We're going to talk about the challenges facing healthcare and clearly, the greatest challenge right now is the safety of our communities and care providers. The work of the frontlines is truly amazing and the word hero really can't be used enough. This show is This Week in Health IT and that is going to be our focus for today. As with everything else we've done, we will figure it out as we go.
What I've done is I prepared a prop to get us started and I'd like each of you to go off of that prompt. If each of you takes three minutes, I'll take a minute and then we'll go directly to the chat questions. If people have questions, either during the opening, or even right now, go ahead and put those questions out there. I'll be moderating. I'll be writing them down, getting them together and then we will go from there. Here's what we're going to do. We'll get started. For the opening remarks, I'd like for you guys to comment on an event or story over the last three weeks that gives you hope and the greatest challenge facing health IT on today, April 28th, 2020. Drex, we'll start with you.
[0:04:23.3] DD: Sure. I think one of the really great stories – so I live in Seattle, the epicenter of the initial outbreak. I've seen how our community has really responded to this and really done their best to flatten the curve. I’m also seeing the amount of innovation that everybody's undertaken. There's actually NPRs. Frontline has a great story about the initial COVID outbreak in Seattle and some of the stuff that's gone on here. One of the stories is about folks in Providence who gathered the admin people, all gathering in a conference room at Providence and putting together face masks from office supply material.
There's a hundred, there's a million of those stories out there where people were super innovative and did whatever they needed to do to take care of patients and families. I'm really proud of healthcare and the people that we work with for that. I think there are a lot of big challenges. Part of that challenge might be and I'm sure we'll talk more about this later, is that we did a lot of things in the near term to get across the hump, right? We knew we were going to have this big bubble from the initial outbreak.
We did a lot of things. We have made a lot of exceptions. We bent a lot of our rules. We did a lot of local process exceptions and other things to get over that hump. I think on the backside for the places that are on the backside of the first surge, they're starting to realize maybe that some of the things that they thought they were only going to have to do in the emergency may actually be part of the new normal going forward. They're going to have to figure out how to adjust to that. I think that's going to be a big challenge for a lot of us.
[0:06:08.4] BR: Yeah, absolutely. Sue, one day – you celebrated your birthday yesterday. I should have allowed you to go first on your birthday, but I will allow you to take the second spot. Happy birthday, by the way.
[0:06:20.8] SS: Thank you. Thank you. That’s okay. I want to talk about Boston Hope Medical Center. You talk about a story that gives you hope. Boston Hope Medical Center was stood up as a 1,000-bed alternate site at the convention center in a week's time. It was with Epic EMR, fully ready. It was done as a coalition effort between the state, the city, Partners Healthcare and the Boston healthcare for the homeless.
I understand it, 500 beds of the 1,000 designated for patients recovering from COVID and 500 beds for homeless patients. The fact that it was done that quickly as a coalition took into account in a very important public health issue in terms of the homeless population in urban areas that have been hit hard. It's just a tremendous success story to me that they were able to do that.
The story, or the greatest challenge that I see at this point is you've got a period of increased demand for technology and IT. I think a recognition of the value of IT during this whole crisis — at the same time, that costs have to come down and financial constraints of hospitals. That's going to be a really difficult balance I think that IT organizations are going to have to deal with.
[0:08:10.0] BR: Yeah, absolutely. David?
[0:08:13.3] DM: Before we get started though, this is a very serious discussion. I want you to know that I have found out that video adds 15 years, 20 pounds and changes the color your hair significantly. You'll have to make sure the audience is aware of that.
The thing that I want to talk about is really something that occurs after the initial interventions at the delivery system and that's a very important thing. Once you leave the care of the provider, what happens next? There's a small – not so small. There's a company here in Austin, actually about three minutes from my house called auntbertha.com. It’s a high trust certified vendor. They characterize themselves as an online social care network. My wife was a certified care manager.
The idea is what are you going to do about the social needs of people after they leave the provider space? Aunt Bertha was recognized, I guess two weeks ago in the Pittsburgh post-gazette about its efforts to help the community. There's a partnership now between Highmark Allegheny Health and Gateway to create a referral network for people who are facing food, housing crises and those who need access to so many other services that are not provided by the health system. I think that's critical now.
The good news is you can go out to auntbertha.com and they're all over the country. Anthem for example, has them on their website. When you look on the coronavirus information page and there are 40 other systems and that the guys endure and Sue, they've got — women's there at Mayo, Sutter Stanford, so all over the country. My suggestion is that you go out and visit that website to help the people host interaction with the providers.
In terms of the biggest challenge, I think that we are in more serious difficulty because we've relaxed the need for interoperability. Instead of gathering data that might have given us more insights, instead of having templates to collect data that would have given us some insights, we haven't done that. It's not surprising given that most of our disaster recovery things have been focused on weather-related events.
We didn't need to collect data, because we didn't need to understand the weather patterns more. In this case, we need to understand disease and care patterns better. I'm hoping that afterwards that we will make a far better concerted effort to get interoperability up to where it needs to be and should be.[0:11:02.5] BR: Yeah. We already have some questions on interoperability, so we're going to be coming back to you on that. I dropped a news day episode this morning, which is my intro, but I'll give you a quick rundown of it. I've been categorizing this as a reset for healthcare. Now I think I'm going to go a little further and say it's like more an event that we're going to keep time from, like AB-BC, or I guess BC-BCE, depending on when you went to school.
We're going to talk about healthcare pre-COVID and healthcare post-COVID, I think for the foreseeable future, if not forever. For an industry with the reputation of being a laggard and moving slow, we exceeded everyone's expectation in health IT. They threw a lot of challenges our way and we handled it. Work from home, telehealth, reduce the touches with infected patients, reduce the need for PPE, stand up field hospitals, bring family members into the room virtually, drive through testing facilities, incident slide centers. I mean, the list just goes on and on. We flat out did great work, amazing work.
The reality is we're at the top of the mountain right now. We should take a moment, pat each other on the back from 6 feet of course, but get ready to come down the other side of the mountain and it's a pretty treacherous descent that we're looking at. I think the biggest challenge we're going to be facing is financial. If your organization had a healthy balance sheet, your descent is going to be loaded with even more work at a really frantic pace to take advantage of the environment. Medical groups will be purchased. Health systems and capabilities are going to be acquired. If you had an okay balance sheet going into this, you have to figure out a way to get the revenue stream moving again and moving quickly. The challenge with that is people don't feel comfortable going to a hospital. People aren't sure whether to go see their doctor. They're not sure whether those are safe environments to go to.
We're going to be called upon to try to help figure that out. What does that look like to restore that trust? Do we need to create a new model for COVID and non-COVID care environments, so that the trust, to know that the place they're going is a non-COVID type of environment? Organizations with a poor balance sheet, I'm not going to say that they're in trouble. I'm going to say they have an opportunity, because what they were doing before COVID wasn't working. The nice thing about change that's thrust upon you is once you're changing, it's easier to continue to change. Coming out of a – you don't have to generate any momentum. Coming out of a crisis is a good time to change what you've been doing, because it's just easier, because the momentum has already started from what we've experienced. That's really a synopsis of what I've been talking about.
What I'd like to do is we received a handful of questions ahead of time. I'm going to throw a couple of them out. Give me a chance to look at the questions that have been coming in on the chat. Let's just start with what do you think organizations are looking to prioritize when things get back to normal? Does someone want to define normal first and then we can define what organizations are going to be looking to prioritize? Who wants to take that one?
[0:14:37.6] DD: Well, go ahead Sue. Go ahead.
[0:14:39.7] SS: I’ll start. None of us can define normal. The analyses and things that I've been reading talk about three stages and whatever you call them, the crisis now, the recovery, stabilized period and the new normal. I think as you said in some of your prep notes, the re-imagine what could things be like in the future.
I see several things in terms of what organizations from an IT perspective are going to need to prioritize. One, I think is hardening the infrastructure and security. I mean, we know that there's been a lot more security incidents and phishing attempts during this period aimed at healthcare. If you had trouble scaling up and getting everybody working from home and getting your telehealth up to what it needed to be, you might need to come back around and look at how to you harden your infrastructure.
I think that accelerating any core work around EHR rollouts is also going to have to be a priority, because you can see the dependency on having that common integrated solution. I think that analytics is going to be placed at higher value and the investment in analytics will be important for organizations. I think that interoperability, which David can talk about a lot is going to – a need to focus on.
I think that looking at how is care delivery, especially in a post-COVID and what's post-COVID. When is post-COVID, right? Is post-COVID in a few months when it slows down and flattens? Is post-COVID 12 to 18 months when we have a vaccine and treatment? Until then, how patients are tested and traced and monitored is going to have to be something that organizations have to figure out. I think the last thing is the front door into the hospital, the digital front door, how patients interact with their physicians, not just telehealth, but how do they get access, how do they get answers, etc., is going to be that much more critical. Would be my list, to start.
[0:16:54.5] BR: Drex, do you want to jump off of that?
[0:16:55.7] DD: Yeah, I'll jump off that. I mean, I think that's a – first of all, Sue, terrific list. I think the challenge for a lot of health systems now will be they had a list of projects and if they had good governance, they had them in some priority order going into this. I think the new normal reality of how they're going to reprioritize is largely going to be based on their experience with the world that they've seen over the last six or eight weeks. The other thing I think is that the idea of having a concrete cement, here's our list and we're not going to bury from that, which a lot of health systems go through that process every year. Here's the list. This is number one. This is number 99. These are the projects we're going to do in this order.
The conversation is going to have to continue to be really agile and change and people are going to have to get really comfortable with that uncomfortable feeling of change and adjustment all the time, because I think the analogy of a war is actually a pretty good one. Depending on where you are, you may be fighting bigger battles than others and other parts of the country, or other parts of the world. That experience is going to inform the decisions that you make about how you prioritize going forward. It's going to be an interesting dynamic process, I think as we get into it.
[0:18:26.2] DM: Bill, can I just jump on one more thing that we didn't talk about, but I think is a critical. By the way, great comments from both speakers there. I think, one of the things we're going to have to look at is the role that the patient has now as it relates to what you would define as the new electronic health record.
We used to all have it in one place. Now it's scattered throughout and we used to have HIM professionals, or health information management professionals who would define what the legal medical record was. Well, legal is interesting, but what we need is something practical and pragmatic. Before, the HIM professionals were considered the custodians of the record. I think what you will see is that patients will now be forced to become custodians of their records. It's going to be important that we educate consumers on how to become good custodians and how to validate the integrity of the record, which we know sadly has been a challenge going forward.
We know that OpenNotes is out there and there's been a lot of participation, but OpenNotes assume that you've got an organized health care system that's easy to traverse and now I think we're going to need, if you will, record navigators to help people figure out, not how to navigate the system, but how to locate information that's pertinent to their care and to their future.
[0:20:02.4] BR: All right. I'm going to take us to the questions. Before I do that, my comment on this is we're going from one crisis to another. We're going from the COVID crisis to a financial crisis. The one we need to look at the most is the 2008 financial crisis is the greatest corollary to what we are currently, or we're getting ready to go through. We are going to step out of one crisis and go straight into another. Prioritizing the projects is going to be on, how do you restore trust? How do you restore the revenue stream? How do you – I mean, how do you shore up your medical groups?
Most health systems are going to lose 10% of revenue, if not 15% of revenue, maybe as much as 20% of revenue this year. A lot of emphasis has to be put on that. The other thing is we are stepping into probably the greatest opportunity that health systems have had as well to redefine what we have done before to reimagine is what I keep talking, I keep saying. We have it and we’re starting to use chatbots in ways that we – we're dipping our toe in before and now we just got a ton of experience on how they can front-end care and virtual care and how it can really change how we offload some of the work streams and change the work streams.
We've just gotten a lot of experience on how things can change. We could potentially, fundamentally shift the cost structure and the access model for healthcare. Before we do that, we have to recognize we're stepping into a financial crisis for healthcare that needs to be taken care of. The other thing is just judging from these questions. For some reason, we believe that healthcare should just be bailed out. Every health system should get 50 million, 50 billion dollars sent to them. That's not going to happen. It's just not going to happen.
By the way, it didn't happen in the financial crisis. Somebody made this case to me yesterday on the show, or recording I did on the show. They said, “Hey, they bailed out the financial, the banks, they should bail out all that health systems.” I’m like, “They didn't bail out [inaudible 0:22:09.7].” There's a whole host of and you can look at the list of banks that when went bankrupt from 2008, 2009, 2010. We have to address that. We have to restore confidence in people going to the doctor. I know I said a lot there.
Let me let me give you some of the questions that are coming in at this point. There's stuff on the financial impact. That’s project priorities. With rapid adoption of tech to scale, COVID-19 responses and adapt to social distancing with virtual care, what do we need to be aware of as we make quick decisions on what to invest in and buy? Do you think organizations are going to make investments? In what technologies will they be looking to make investments in the near term to sure up some of the things that we've been doing? Who wants to take that one?
[0:23:07.4] DM: Can I jump a little bit onto the question before and then I'll try to relate it to the question you just raised, but the comments about the financial impact. I think I've heard more discussion in fact almost exclusive discussion on how people are going to do activities that are going to help shave expenses. I'm not convinced that that's the right thing to do.
It's not the only thing you should do. It's obviously going to be critical. I think the other thing that we need to look at is what are the revenue opportunities that we're going to have going forward that will be enabled by the technologies that we put out there? For example, I can tell you that I had one of the shortest visits I needed to establish cardiologist here in Austin. The visit went very quickly.
Unlike the normal visits, instead of taking notes and looking down at the computer the whole time, he was looking at me the whole time and still taking notes. The question is how many more patients will you be able to see? How many more activities will you be able to deliver more cheaply by focusing on revenue enhancement at the same time? That's one thing. I think the other big issue and we talk about what we're going to do for the patients that seems relatively straightforward in terms of distancing and doing the things that need to be done.
You just had a conversation last week with [inaudible 0:24:39.8]. What are you going to do protect the employees who need to come back to the work place? I'm concerned about the configuration of all the office space and where we used to try to cram as many people into the prairie dog fields as we could by putting up barriers. Now that's going to be insufficient.
I think the teleworking, though it was something I was a little skeptical of a couple decades ago, is now an effective norm. I think that enabling the staff to be more effective remotely is going to be critical. That I think is part of the answer to the question that you posed.
[0:25:25.6] BR: Yup. Drex, this is one for you. Do you think we have to set – do we need to sacrifice privacy in the new normal?
[0:25:36.5] DD: I think it's interesting that HHS decided to relax HIPAA privacy and security rules in the heat of the battle here. I think that when we all look back to HIPAA, whatever it was, 1995, there was probably good consensus around that was really great for 1995, but maybe we need to rethink what we do with privacy today.
I think this is as we move forward, we really are going to have to rethink how and what we do with privacy. David's point about patients taking a more active role in managing their own medical records and being the custodians of their own medical records, I think that as we move through this and move into the era of I'm going to be able to have my medical record on my phone and I'm going to be able to participate in research studies that I choose and that I decide what information I'm going to release to that researching organization. All of that is it turns a lot of the privacy rules that we have today on their head. We're going to have to rethink this whole idea. I'd like to hear David's thoughts on that though, given his policy background.
[0:26:58.3] DM: Yeah. I can tell you, I was alarmed by the fact that you would set aside privacy. There are three things that we need to be talking about. I think the three that are you can't disconnect, that's privacy and confidentiality and security. The idea that we would give them up in a crisis is exactly the opposite of what we should be doing.
It's in those times that we should have already created this. Now, I started in bloodbanking. When the AIDS crisis hit, we had to put up soundproof barriers for people who were being questioned about donations, about their sexual preference, their sexual activities to protect the blood supply. We did that in less than a week, as soon as the rules came out. The question is why in a crisis would you abandon these things?
I agree with you, Drex, that you need to come up with new or appropriate rules. We'd say in the case of a disaster, you still have to protect these things, because there is a sacred trust that patients put in their caregivers. That has to be protected. The security thing is just off the charts in terms of things and I know that’s your area of special interest, Drex.
Again, what can we do to educate the public? As the records move from one central location to if you will, the mobile phone as you talked about or something equivalent. What are we going to do to protect the security there? I think we've got an opportunity-rich environment here. Policy, by the way, is just a start. The challenge with policy is that it has to pass the test of pragmatism and practicality. We have not had a stellar record of doing that.
By the way, part of the reason for me going to Washington was try to add back those two factors into the policy-making fabric. I would suggest that anybody who has an opinion here, regardless of whether it agrees with mine or not, needs to participate in the policy-making activities. When questions come out from your government, our government, you need to participate and respond, because they need to know the diversity of opinion, not the ones who are the strongest or are most wealthy.
[0:29:27.7] BR: Sue, I’m going to meld some questions here. There's going to be an awful lot of requests of CIOs. There's going to be a bunch of projects. There's going to be a demand for just a ton of work, right? There's an opportunity to really overwork our staff by not prioritizing, not having the right governance. How are we going to deal with this? How would you deal with this as a CIO to make sure that the right projects are being done, your staff is not being overworked and the right – you're heading on the right path?
[0:30:00.8] SS: Great melded questions. Every organization I've been in as a CIO, whether permanent or interim, seem to have gaps around governance. You would think at this point everybody has good governance, but everybody needs improvement governance now more than ever. I think that one of the things that I've seen in meeting and watching and listening and talking to people is that that partnership around decision making between IT, the business leaders and the clinical leaders has gotten that much more effective in a crisis for quick decision-making.
How do you capture that and how do you keep that level of partnership, keep that level of engagement to strengthen your governance, to make sure that you are in fact working on the right things, prioritizing the right things? For every IT team, that was already overworked with too much to do, making sure that you're taking care of your people and you're being very clear about how much can get done with the resources that you’ve got? I mean, I always say the demand is insatiable, the resources are limited. How do you balance that demand? There's some fundamentals there that just need to be on steroids, I think at this point in the scope forward.
[0:31:20.9] BR: Yeah, it's interesting that we still struggle with governance at this point. It's not like we haven't been talking about governance at hymns since I came into healthcare back in 2011. I'm sure you were talking about it in 2007, right? Why do we still struggle with this? Because it is going to be fundamental right now.
[0:31:42.2] DM: Let me jump on that one. I think it's the value proposition – oh, sorry. Sue you maybe answer that.
[0:31:47.5] SS: Well, there are so many – I think part of it is nobody wants to say no, right? When I was a CIO at pregnant women's hospital and I was appointed to the COO and she said, “You know, Sue. We've never seen a good idea we didn't like. It's just so hard to say no.” When you look at strategy and prioritizing, it's all about what are you going to say yes to, what are you going to say no to, what are you going to say yes to, but not yet? Go ahead, David.
[0:32:16.8] DM: One of my favorite things, sounds like a coach that would have said it, but I used to tell my staff that we need to make sure that everybody who comes to us understands one thing. That is that we can do anything, we just can't do everything. That was the biggest issue. I think the comment I was going to make before is the valuation of IT is so different than the valuation missed assets. The people who are trained and masters in the health administration have not been and may still not be trained in how to evaluate IT investments.
The methodology that looks at just ROI is insufficient. It needs to change radically. If you looked at the ROI of a cellphone versus a landline 10 years ago, this was the question they posted to say, “Oh, why the heck did you buy the cellphone? It fails calls and the quality is terrible. You have to recharge it every night. In a disaster, there's no guarantee that you can make the calls.” With a landline which is cheaper, none of those things are a problem.
The answer is there are other capabilities that you have that you can do flexibility, that will be created safety that you can't get with any kind of a advice, mobility. There are many measurable intangibles and tangibles that need to be added to the ROI. As part of that governance discussion, Sue, I think it's important to add in to that. How do we evaluate our investments in IT essence?
[0:34:05.3] BR: Yeah. I didn't talk about the financial to create alarm, because I know some of these questions are learned at my financial comments. It was to say that the number one thing I heard from CIOs and we've now done about 30 CIO interviews on the show, was focus. COVID-19 gave us focus. The reason we were able to get so much done is we knew exactly what we should be doing at every moment of the day.
The reason I say restore the trust to the public and take care of the financial side of it is to provide focus, so that when things come into the governance group, we're not saying, “Hey, yeah. It would be great to set up that study, or that thing,” because there are parts of our organization that aren't grounded in the fact. It's still a business. As the sisters would say, no money, no mission, right? We don't get to keep doing what we're doing if we don't have money. That's coming from the sisters and started this thing as a ministry. They understood at the end of the day that is the fuel that keeps the thing going.
I think we need some organizing principles that allow us to stay focused coming out of this. That's going to be the hardest thing that's going to keep us focused. I did want to hit some of these on interoperability and data. There's a question here of oh gosh, they're sprawling up. Sorry. It was on patient ID. I think patient identification and matching is a key – has been key and highlighted in this pandemic as care was delivered in temp locations, also relates to tracing and tracking. Then we have other questions over here which came in earlier, which is what types of interoperability challenges that we face. If we had better mechanisms to share data in place, how would that have impacted our response to COVID. We threw that around beforehand and we said, we'd give David the first shot at this. David, do you want to take the first shot at this?
[0:36:14.5] DM: Yeah, yeah. I think it's the greatest disappointment that I had in my career is that we have not been able to achieve the level of interoperability that was imagined by both President Bush and Obama. They were great supporters of creating electronic health records. I served in the administration and I had some responsibility for this.
Again, the discipline that was necessary to make the investments and interoperability just wasn't there. There are if you will, there were some perverse incentives on not making healthcare plug-and-play. Now I can tell you that if I go out and buy a printer to hook up to my machine, which Apple, or PC, I am not going to pay extra for the drivers that are necessary to make it function with all the other equipment that I have in my house. It just happens. We have plenty of models of how interoperability should work in the commercial space and we need to adopt those.
The biggest missing piece is the thing that you brought up, which is the patient ID. Right now, we seem to be willing to accept arithmetic solutions, which is we have a certain degree of belief that the person we saw based on some information we gathered about them lead us to believe this is such-and-such patient. Patient matching as it stands now is a good interim step, but at some point it's going to take biometrics and not just one kind of tricks and user controlled ID to get us where we need to go in these crises.
When I was in the government, we used to say the real test of interoperability is how do you get the records on somebody who appears in the emergency room naked and unconscious? If you can't achieve that level of interoperability, you're not where you’re supposed to be. By the way, a lot of people are coming to the ED now, unconscious. I think that we need to redouble our efforts. We have seen some progress made recently in interoperability, the Sequoia project and commonwealth. There are ways that we can – there are networks of networks that allow us to connect. Still, the meaning that is shared in those messages is insufficient to provide the care with the confidence that you need. We've got to come up with a better data curation that guarantees that the people are collecting the information to understand the downstream impact of it and are packaging it well. I think FIRE provides more constrained standard that will help us provide the data.
We also used to say, you need to send conservatively and receive liberally. What we need to come up with is better data templates, data sets that are necessary to ensure that we can do public health and some don't mix in surveillance. The good news is all of these things are sitting on tables everywhere. It's just the will of the people. COVID has provided the burning platform, if you will, to make the last push to get to true interoperability, where we have plug-and-play interoperability. It doesn't become a source of revenue. It becomes a source of pride with all the vendors who are out there in that space. Step down off my –
[0:40:02.8] BR: Does anyone want to comment on that? I mean, my only comment is I disagree a 100%. What are you guys – anybody else want to comment?
[0:40:11.5] DD: I mean, I feel I've been standing on the mountain of rocks, yelling about universal patient ID forever. Whatever it turns out to be, I just feel at this point, if we're going to do the syndromic surveillance that we intend to do, the way we're going to have to track patients and where they've been and what they've been in contact with, I mean, there is a few things there. One of them is that we need to know who these individuals are without any doubt, that person is that person and they were in contact with this other person.
We may not get there overnight, but I think it becomes critically important long-term part of the solution about how we're going to be able to track, not only COVID, but whatever's next and whatever comes next after that. When you pile on that with the analytics, you start to really think about how healthcare as we think about it today isn't just the stuff that happens in hospitals or clinics, but it's in many ways, the way we live our lives and where we go and what we touch and who we interact with, that's a lot of information that needs to go into that analytic pool to really figure out how to keep people healthy. That's how we're going to have to think about all of this going forward.
[0:41:31.7] BR: Yeah. I mean, my job is to spark conversation. The reason I disagree wholeheartedly is because health systems had their chance, they messed it up. I think the locus of the data should be with the patient. Patients should carry it around. The ID should be whatever ID – I mean, I have 10 IDs that identify me as Bill Russell. I don't need another one. Quite frankly in this crisis, they're like, well, we needed all this information pulled together. If you don't think that the American people would have given their records to fill in the blank, it would have probably been a lot easier process to make that request to the public than it was to try to figure out how to go through Epic and Cerner and the health systems and navigate legal and compliance and get back.
We covered this with [inaudible 0:42:22.8] of how they actually ended up doing it. They did not aggregate any data to do the analytics they needed to do. They sent the analytics down to the health systems, they ran the analytics and then just submitted the results back to them. By the way, contact tracing should not be done in a way that can trace that it's me here, here, here and here. Now it could be my phone and we talked about this also with [inaudible 0:42:46.8] that the thing that Apple is working on, I don't trust Google, but the thing that Apple and Google are working on essentially will allow us to know which phones were near each other, so that in the case that I am COVID positive, that those phones can be contacted to say, “Hey, you were close, or in contact with somebody else.”
It doesn't need to have a patient identifier to do that. I would hate it to have a patient identifier. We already know that Google can map everywhere you've been. Privacy is out the window if you have Google Maps on your phone. Probably is going to lessen my likelihood of getting a Google interview, I'd imagine at this point saying these things. They have to start coming towards where Apple is coming, which is your privacy, your data. I mean, that is the direction, that is the reason we're struggling with the fact that Google has so many health records today.
[0:43:44.7] DM: Bill, just to make a point here. When I rambled on, what I said was a user controlled voluntary ID. The idea was it should be in the form of e-mail. Just like you do today, you decide who gets what e-mail for what purpose. If you wanted to, you could give it out. If you didn't want to, you don't have to. The idea is if it helps increase the certainty that you will carry – that you will know who I am, we're going to make sure I get the right care at the right time using the right data, then I think as long as it's voluntary, then it should be offered.
Again, it's a patient choice. It's not something the government insist upon. The biometrics are the only solution I see that will help guarantee the person. The problem with that is that it impinges on privacy. We need to have the discussions about ethics and morals of privacy. Again, as long as it's voluntary, as long as I've made the choice to help me or help my family members, I want the infrastructure to support it. Again, not trying to force you to get the choice, but to give you the choice to on how you're going to collect the data and use it.
The patient as a custodian is just what you talked about. That is I'm in control of the records. I get to decide who gets to see them under what circumstances, which is by the way what I do now when I'm in a care setting. I decide either I'm going to share my social history, my psychological history or not. I think we're in agreement, we just start using the same terms.
[0:45:28.3] BR: Yeah. I'm sorry, I'm reading all this stuff. They have a really interesting conversation going on in the chat, because well.
[0:45:37.3] SS: Bill, if I can make two points before you go into our next questions, related to this terms interoperability. I would say two ahas that I've had during this period as I've watched and listened. One is where as health information exchanges seem to have been much more state than regional, even though we think of them as regional, I think that obvious regions and patterns of movement of people and patients has become clearer during this time.
You take the Northeast for example in the states that New York and other states mine, Rhode Island, that are now working together in terms of how they come back and the response. I've heard the 95 corridor reference. I’m in Rhode Island sitting between Boston, a hot spot in New York. How much regular people traffic is there through those states? When you think about sharing information and making that better at a regional level, that's one point. Secondly, I think the huge multi-state health systems in this country, we probably have a lot to learn from them in terms of the challenges that they have had dealing with numerous state regulations that vary. They are working in all of those environments. I look forward to hearing more from what they're going through and what they're learning, as we all share together in this industry, yourself included, Bill.
[0:47:11.7] BR: All right, so here's Greg Walton. What are the top three major actions you would recommend providers to take next? By the way, Sue. Happy birthday. That's from Greg, by the way.
[0:47:24.4] SS: Greg.
[0:47:25.5] BR: What are the next three major actions do you think as CIO should be considering?
[0:47:34.4] SS: Is that aimed at me or anybody?
[0:47:36.7] BR: It's aimed at anybody.
[0:47:40.8] DM: Let me go ahead. I’ll take the first one. I'll just mention one and then move on quickly. I do believe we've been talking about IT and I think that nomenclature gets in our way. I think that what we should do is change the terminology. I'd like to see us refer to ourselves now as digital health services, because it's so much broader than just IT. As we talked about the changing rules of the CIO, if the CIO doesn't convert to become the chief digital officer in lowercase letters, if you will, and if you don't convert your current health system into a digital health system, I don't think you can prosper. Or not just survive, but you can't prosper.
I would think that what you want to do is create a digital roadmap for how it is that first, you're going to recover and then how you're going to move forward, so that you are giving people, treating the wounds they have that the sun-time is providing hope for a much better way to avoid these issues going forward. In a true digital health system, where interoperability is a given, we would have had the insights a lot earlier and we would have a lot of insights from data we gather to be able to treat this far more effectively in guessing why some 38-year-old suffers, why some 38 comes through it without any difficulty, whatsoever. Change IT is a way to refer to us as professionals to digital health services would be –
[0:49:18.4] DD: Digital health services, or I mean, I think about it too as we've gone from IT to information systems, to information services. That's really what we are and that's really what we should be. One of the things that I think that we really have to redouble our efforts on and think about is cybersecurity too and Sue brought this up earlier. With not only securing individual systems, but the way that we're collating data from multiple systems and to lots of different databases right now, we put ourselves even at or risk, because the crown jewels now are in lots of different places, not just in the EHR, or just in the rev cycle system. We need to think really carefully about that.
Like I said earlier, the part of the challenge in all of this has been in the heat of the emergency. We've made a lot of exceptions and we've been broken, or bent a lot of our rules to make sure that we can connect to new suppliers, or we can add new equipment that didn't go through the normal testing process, whether it's IT equipment, or IoT, IoMT, bio-med equipment, whatever the case may be.
One of the things I think on the backside of this is think really carefully about how you're going to run your cybersecurity program, how you're going to resolve those exceptions to the rules that you may have made. I would say this for everyone, not every organization has all those capabilities. You should think about, are there partners that I should be looking to to help me with some of that stuff? You don't necessarily have all those capabilities in-house. They're hard to come by. A lot of those cybersecurity people and other people are really rare. Don't be afraid to go out to partners if you need to.
[0:51:06.8] SS: I want to answer this question too. Two threads, I'll say. One is as a CIO, you are also a leader of however many people are in your IT department, regardless what you call it. I don't disagree with you, David, on the digital health services. You need to understand the impact that work from home has had on them. You need to look at what's going to be possible in the future in terms of work from home. Just make sure that you're staying close to your people. As you reinvent IT, because you have that opportunity now, make sure you take into account all of those people issues.
The other thing I want to comment on is in the context of innovation. I've seen many organizations where there's IT over here, keep the trains running, get the EHR in, get the ERP in, da, da, da, da, da. Nobody can bother them for something innovative, because they're too busy and then some innovation group, somewhere else in the organization on some parallel track. When you look at how quickly and how agile and nimble IT groups have been, making solutions happen in this last two months, I think it's the foundation for whoever owns innovation, if it's not IT to be partnering much more closely with IT and for IT making that happen going forward.
[0:52:27.4] DD: Those our IT leaders, those CIOs are the original innovators, right? I mean, I think back to our early days as young people in IS departments and IT departments, we were innovating – I mean, it's what we did. I totally agree with you, Sue.
[0:52:45.8] BR: All right. I guess, we're getting pretty close to the end here. Jeff Duke, I'm seeing lots of HIT shops furloughing or laying off staff, cutting projects, etc. Will we permanently lose this talent?
[0:53:05.1] DD: Boy, I hope not. I hear one of those, please don't cut your nose off to spite your face kinds of things that I have heard about in a couple of different health systems is we've laid off our project management team, because all of our projects are on hold. There are situations like that where I clunk myself in the head and I just think to myself, there are going to be projects and project managers, by their very nature are the kinds of people who can in a crisis, help prioritize and organize and understand what those exceptions are and keep track of them. That's what they do. Those are those are some of the last people you want to let go.
I think you can probably say that around anyone that they've decided to layoff in an Information services department. I mean, think very carefully. I know there are a lot of folks that are very stressed right now and are making these decisions under an enormous amount of pressure. Once you've lost those people and you try to invite them back later, there's going to be a lot of hesitation about taking you up on that offer.
[0:54:24.3] BR: Drex. I mean, how this happened, right? You just get the phone call that says, “We’ve got to reduce [inaudible 0:54:29.8].”
[0:54:30.1] SS: There’s many FTEs.
[0:54:31.6] BR: 15%. What is your plan? You don't want me to fire anybody, you don't want me to furlough anybody, you don't want me to let anyone go, what's your plan? I'm going to put you on the spot.
[0:54:41.6] DD: Yeah. I mean, I mean, these are the kinds of things that I think you have to think about in advance too, right? That you don't take a slash-and-burn approach to this stuff. Before the crisis, you should have probably already thought through that if I absolutely had to, here's the first 25 positions that I would eliminate and why and how you would go about that? Think through that process, get that plan ready to go, so that you understand what you – what you're dealing with. What I hate is that sometimes I see the approach, where the call comes and they say you have to eliminate 12 positions and that turns out to be exactly the number of people in this part of the department. We're just going to cut all of them, right? Think about it. It’s not –
[0:55:30.4] BR: Well, but we have 12 PMs. Oh, that's perfect. We’ll just [inaudible 0:55:33.5].
[0:55:34.1] DD: Yeah, exactly. I mean, if you had 12 PMs, that's a huge amount for most places. Yeah, it's just a matter of don't react. Think through these things, because they have really broad long-term consequences for you and for the patients and families too.
[0:55:55.5] DM: Can I just jump into this very quickly? I was faced with this every single year in budget time as an IT person. First of all, the governance process, if you've got demand management and you know what people are asking for, you're facing this every year. What I used to say is I'm not going to cut 12 positions, but what I'm going to do is I'm going to impact these programs in this order.
If you want to make the cuts, I'm more than happy to do so. I mean, I'm not thrilled, but you're going to make it far less difficult for the rest of us, but we're going to have to shut down this part of the laboratory with these images we're not going to get, we’re not going to be able to provide the services, we can't do the on-call, or self-service for the patients, then I'm okay with that. But I just wanted you to understand what you're asking me to do. It's not 12 people that I'm getting rid of. It’s 42 programs that you had lined up and were valid requests when they were submitted. Let's use the governance process to figure that out.
[0:56:50.7] DD: Absolutely. It's a great conversation with your business and clinical partners, right? Put them on the spot to help you make these decisions. Don't try to just make cuts and then in the spirit of let's just keep everything going, we can do it with 12 less people. You can't do that. You have to have those hard conversations.
[0:57:10.8] BR: Yeah. I mean, these are extraordinary times for sure. I would love to tell our listeners that you should feel guilty if you let anyone go, but some of us are going to have to let some people go. It's going to be difficult decisions, because those people have to go home and sit across from their families and say, “Hey, I lost my job today.” I don't think anyone takes that lightly. It's just part of the realities — I think that's part of our jobs, so I didn't answer that one question.
Part of our job is to partner with legal and really understand the ramifications. Partner with people that are going out for money. There's money available through the FCC for your telehealth program. Partner with clinical to determine hey, how many of these new models for care are going to give us the ability to be much more efficient, drive our costs down and not have to furlough as many people, or change our business models? I think right now, the CIOs will – we feel we've earned our chops, because we got them top of the mountain. I think we're going to earn our salary over the next 12 months leading, leading effectively, saving jobs, protecting people in our community and that's what we get paid to do.
[0:58:32.3] DM: Just one last reminder.
[0:58:33.7] BR: Yes, sir.
[0:58:34.3] DM: That every termination for whatever reason is very personal. When people used to say, it's just COVID. It's like, “Nope, I'm sorry. But you made a decision that impacted me and that is a personal decision that has an impact on me, and my family, friends and community.” Avoid using the term, it's just business. It's actually personal and you have some responsibility as Sue pointed out to be a good shepherd for everybody that you've been benefiting from, who's effort you have been benefiting from.
[0:59:05.0] BR: Well, I want to thank you, guys. I couldn't have imagined a better panel and I really appreciate all your input. Sue, we were going to sing happy birthday to you at the end, but unfortunately, we've run out of time.
[0:59:18.6] SS: Yeah. Bill, thank you for having us and all you're doing. Your field reports are incredible. It's a sharing industry and what you've been able to put out there is just really valuable. Thank you for all of this.
[0:59:34.6] BR: Well, I appreciate it. I'm going to just throw the close on here for you guys. Again, thanks everybody who came on the chat and thanks for all your support of the show.
Hey, best way to support the show, just tell someone you're getting value out of it, refer them to the website, we’ll probably start planning right now what our next live session will be and if you have ideas for that, just shoot me an e-mail. I'd love to hear about that. Keep checking back. We're going to keep doing these shows. Thanks for listening. That's all for now. I got to figure out how to turn it off. Let's see. Stop live stream. That will do it. There we go.