Bill Russell: 00:02 Welcome to this week in health it where we discuss the news information and emging thought with leaders from across the health care industry. It's Friday, March 2nd this week. What is the future of hospitals, epics, new Sonnet Ehr, and what it means for interoperability. And we dive deep on the role of technology and physician burnout. This podcast is brought to you by health lyrics, a leader in digital transformation in healthcare. This is episode number eight. My name is Bill Russell, recovering healthcare CIO, writer and consultant with the previously mentioned health lyrics. Today I'm joined by a relatively new friend and first person to appear on two episodes of the show, Dr. David Bensema former Cio of Baptist health in Kentucky who had started his second round of work in his, I guess your pre retirement phase of retirement. As we all know, you don't just go off into the sunset, people tend to pull you back into work. So, uh, good morning David and welcome back to the show

DrDavid Bensema: 00:59 Good Morning Bill, appreciate the chance to be here again.

Bill Russell: 01:02 I'm looking forward to our conversation. A lot of good topics this morning. So, uh, this appearance is, is through a scheduling mistake on, on my end. And I appreciate you being so gracious to come back on the show. So, so normally we ask our guests, you know, what are they working on? What are they excited about? I guess since you're the first returning guests, we'll modify it a little bit. What, what have you been working on since last time we spoke and, and what are you, what are you excited about these days?

DrDavid Bensema: 01:26 Yeah, well, actually you stimulated what I'm excited about at the moment. Uh, you wrote an article about a budgeting and the need to plan to cut today for tomorrow. And it got me thinking about the process that we had put together. So I just submitted, um, a, uh, east to health system to cio.com on the daily discipline of budgeting. I'm hoping that people can understand that budget cycles shouldn't be as traumatic as they've been in the past and, uh, provide some insight from the three and a half years of stumbling that I had. So hopefully some others can, uh, find a smoother path to their budgets.

Bill Russell: 02:04 Yeah. And there's a lot of awful lot of talk going on right now around reducing the budget as more and more pressure comes on the, on the hospitals from a budget standpoint. So did you just recently write an article for a health system CIO

DrDavid Bensema: 02:21 just submitted a, the final draft yesterday.

Bill Russell: 02:24 Great. So can you give us like a preview of what you're, what you discussed in the article

DrDavid Bensema: 02:30 part is that your managers have to have a regular cadence of looking at their human resource spend, uh, to be able to track when weather on contracted or employed individuals. They're getting out a line, either a positive variance, in which case you want to find out how can you perpetuate that positive variance or the negative or harmful variants where you've gone over budget and catch it early so you can make course corrections and uh, make sure you don't let something balloon because the HR spend is our biggest. And then the other piece that I think is most relevant is in years and my role and then other CEO's and executives role set the example. And so we don't need the latest bright and shiny. You and I answer emails. We do some podcasts, we do some webinars, but we don't need the most powerful lightest laptop in order to do our job. And I think showing that fiscal restraint is a good example for our teams.

Bill Russell: 03:32 One of my vice presidents used to have the oldest iPhone he could possibly have because he wanted to communicate to the organization that really the iPhone hasn't changed much since you got bigger screens and whatnot, but it really hasn't changed much in terms of its functionality. And he wanted to show them that essentially we're still doing the same things we were doing then. And he also wanted, he was sort of a no man left behind kind of thing. And he said, you know, I will be the last person to get the newest iPhone. So once everyone in the organization has one, I'll move up. And uh, and I think people appreciated that. They appreciated the, uh, the fiscal restraint and the fact that it wasn't the one walking around with all the shiny new objects while the rest of the organization was a stumbling along.

Bill Russell: 04:16 So that was a great move on his part that a lot of news. So let's jump into the news has, uh, you know, First Section, David and I have each selected a story to discuss and I'll go ahead and kick us off. So the future of hospitals is a, an article that appeared in the Wall Street Journal, uh, this past Monday in the health healthcare section, which is a great section if you, if you get that. I, uh, I'm a former paper boy. So no matter what I do, I always have one paper delivered to the house so I can, so I can read a newspaper. I, it's just old habits die hard, but so we get the Wall Street Journal. Great. A great article. Let me give a recap real quick. The days. So, uh, first couple of paragraphs the days of the hospitals. We know it, uh, maybe numbered in a shift away from their traditional inpatient facilities.

Bill Russell: 05:06 Healthcare providers are investing in outpatient clinics, same day surgery centers, free standing emergency rooms and micro hospitals, which offers few as eight beds for overnight stays. They are setting up, uh, setting up programs that monitor people 24, seven in their homes and they are turning to digital technology to treat and keep tabs on patients remotely from High Tech Hubs. They go on to talk about the economic drivers. There has been a fewer admissions, fewer a overnight stays. Uh, although the patients have gone up and essentially what they're saying is there's just an awful lot of economic drivers. One of the, uh, one of the sections that's cut out from the story, they have some statistics of the total savings, inpatient versus outpatient. For instance, a hysterectomy. There's a total savings about $4,000 per procedure, uh, 480 out of pocket. Uh, they go on with, uh, cardiovascular, uh, angioplasty and they just have these numbers.

Bill Russell: 06:08 They're, and there, they're pretty significant numbers. Having the procedure done in a, in a traditional hospital gets to be a pretty costly. So, uh, I'll summarize where do they think we're going? They, uh, they believe hospitals are going to more helping patients at home and they, Saint Mount Sinai as hospital at home program, which has saved Medicare $45 million. They're talking about building smaller facilities and I have personal experience with this. So we're doing, uh, my companys doing some work for my hometown, a hospital system, and there's literally a street corner that has three buildings for us. Saint Luke's university health network. And each of the buildings represents, almost represents a different department that used to be in the hospital. You have women's on one orthopedic on another oncology on the other, but they're smaller buildings. Nice big parking lots, easy to navigate. If you're going there. They're finding new uses for old hospitals.

Bill Russell: 07:04 Uh, I thought the most interesting part of that was a Geisinger set up of a food, a fresh food pharmacy. Uh, they are, uh, they're converting so that the community, that the community actually has a 50% predisposition towards diabetes and they're recognizing the whole population health move, that if we really want to get in front of this, it's better to help people with, with their food and then help from afar. And we've talked about this before. Hca, inner mountain and mercy health and Saint Louis all have digital hospitals set up and they're providing services to rural facilities. They're providing services to even some other large health systems where they're monitoring, uh, you know, certain situations and, uh, even, uh, some, uh, post postop and, and those kinds of things. So they're, they're providing remote support and some expertise, uh, through that. So these are some of the things that they highlight in the, in this story.

Bill Russell: 08:00 Um, so let's talk about this a little bit. I'll kick us off. So, uh, you know, hospitals still, absolutely. We'll make up a significant portion of the revenue for health systems in the foreseeable future. There's no doubt about that. The big box hospitals is going to be that. Um, but, uh, you know, what I want to talk about is what do we as CIO's and technologists do to prepare for this, this next wave of change, which is already really upon us. And, um, you know, as, as the phrase goes, we talked about budget already, show me your checkbook and I'll tell you your priorities. And the same is true in healthcare. It show me your budget and I can tell you an awful lot about what you value and what you're going to become and the in the future, uh, future couple of years. Um, if I were looking at health systems budget right now, there's a, there's a couple of things I'd look at.

Bill Russell: 08:51 I'd ask, you know, how much are you spending on things connected to the hospital, new models of care. I see a lot of budgets very focused on the EHR. You know, how many resources are you putting on the Ehr, which is predominantly a system to run a hospital or, or to run a health network. And so much money is being still, even after the big Emr implementations are still being focused on that. And not enough is being focused on the consumer. You know, how much of the analytics budget is being spent on the consumer, how much of the budget is spent on the, uh, on the changing the way we experience health care. And, um, those questions will lead you in the directions you need to, to look within the health system. I believe you need to look within the health system and find some people that are doing some interesting consumer based projects and it may not always be in the traditional, uh, part of the organization and begin to partner with those guys and look for new initiatives that are going to lead. Uh, and this is one of those areas that we lead a CIOs. We identify areas that have promise and, and utilize some of that margin budget that we have to support those and move them forward. So anyway, I thought it was an interesting, uh, interesting article, David. You know, um, I guess my question to you is, have you seen this transition away from hospital strategies, um, in the health systems that you work with? And where do you think this is going to lead?

DrDavid Bensema: 10:18 I think we've seen it to a large degree in the health system that I was with. Um, we started in 2006 already looking to the ambulatory sites, decentralizing a lot of the care imaging centers moved off campus, uh, infusion centers. So there was that, but they were still trying to do it on a hospital based reimbursement model. Now with CMSs declining to uh, to or to approve digital sites that are off campus in terms of a hospital based reimbursement systems are having to figure out how to live on my old primary care budget. I'm an internist by training and practice and we learned how to run things tight and I think hospitals are starting to learn that. And so we're certainly seeing that we're seeing a much more aggressive acquisition or alignment with home health to try to reduce the readmission rates to try to move the care back into the homes.

DrDavid Bensema: 11:12 Uh, we saw a significant investment in the system that I was with right as I was leaving and telemedicine, uh, both for visits. Um, so communicating as you and I are right now, but also for a telemonitoring, a home blood pressure home weights, uh, being, uh, fed back in through to the home health. And I think the other thing that has helped is the investment in the EHR in some systems if they did a good across system integration, allow you to decentralize that care and do a better job of making sure that the patients are cared for, where it's most appropriate for them. And then the final was the ambulatory surgery centers. Um, association. You saw systems that fought that a decade ago and you saw systems that embraced it and partnered with their physicians. And now if you look at the systems that still have a margin, I bet they have some relationship with their independent physicians in an ambulatory surgery center, in an other investments where they didn't fight positions but they joined with them.

Bill Russell: 12:15 I found it interesting, at least for our budget in the previous health system I was at and the, uh, the medical group it budget was, was really kind of poultry compared to the, to the hospital. And there were many occasions where I sat down because we tightly partnered with them, but it was a separate budget and there's many times where we had to sit down with them and they said, well, we can't really afford that analytics package or we can't afford that pop health package. And that partnership became really key because I, first of all, I didn't understand that. And because of the way we did budgeting from the article you talked about, we always have some margin dollars to spend. And invariably it went to those guys. It was, it was, uh, an opportunity to really bring that, those capabilities forward so that we can do a clinically integrated network better.

Bill Russell: 13:06 We can do the ACO better. We could do analytics on that population. We can keep them out of the hospitals. And for some reason, uh, I don't know if it's just history or whatever. Uh, they that side it's been starved and the hospital's been been pretty well fed and uh, do, do you think that's going to continue to evolve and change or do you think we're going to, do you think we're ever going to get to the other side of that because it really does take money away from the, the hospital when I had, I know there's incentives but it takes money away from the hospital when people don't come in for procedures and those kinds of things.

DrDavid Bensema: 13:40 Yeah. And I think we will see that shift over at, I think in the system again that I left partially because when I was CIO it was as we were transitioning to the Integrated Ehr, we were tearing out our existing systems. And so we did bring the physician enterprise under the same umbrella as the hospitals and I was able to communicate to the system executives into the board the need to think about them as a continuum. And I think as more and more people think about the cancer care continuum and drop the walls of the hospital at least figuratively and think about how the patient moves through the system through care, uh, systems will start to shift their budgets and understand that,

Bill Russell: 14:21 okay,

DrDavid Bensema: 14:21 I think it's still going to come down to, you've got to have seen a couple of articles now that, so you need about 62% of your patients, uh, where you are at risk, where you are accepting whether it's capitation or some form of full risk in order to pay for these systems and to make that critical mass that tips you over to being able to successfully do that, then you benefit from reducing your admissions. Right now, you know, we're still trying to drive fee for service in most sectors of the markets and that stops you or blocks you from shifting money away from the hospital.

Bill Russell: 14:58 And I think you should be good model that in a sharp healthcare down in San Diego. If people want to look into that when they have a pretty high percentage of at risk patients and they are um, uh, on, on a managed service contract. So, uh, that's pretty interesting. And you brought up, you know, talking to the board and educating the board. That just reminds me of a, that's probably a good topic for a future episode of the role of the CIO in that. But let's kick to a kick to our second story. Epic. Uh, well actually it's your story. I'll let you give it to us and give us a little recap.

DrDavid Bensema: 15:31 Yeah. So I saw the article and of course we'd heard Judy announced last year that they were going to be introducing new EHR. Options and Sonnet Sonnet is going to be introduced at Himss. Um, my take on the article is that it's kind of like epic light. Um, it, in the article they talk about the smaller hospitals get it at a lower price. It doesn't have all the functionality, doesn't have all the modules, but then they can add them later, which, you know, obviously I'm an epic fan. I installed that Epic, I worked well with them. I think there's a lot of great things going on. But in this, I think there's that blind spot where Judy sometimes thinks that it's going to be world domination by epic. And so this is declared as an advance of interoperability as they do the care everywhere more robustly for epic users.

DrDavid Bensema: 16:25 But it doesn't say anything about how they're going to communicate with the others. And I know they're in this coin project and I, you know, I think there's going to be advances out of that. But this article leaves people with that same sense that you've seen in the editorials and you've heard in some of the discussions that Judy not really playing with all the other players in the market. Um, it's great if you're epic and I, you know, I think she is moving to a comprehensive health record for patients in making the care everywhere more robust, having a social determinants, follow them wherever they are in the US being able to communicate that. So my, uh, snowbirds go down to Florida from Kentucky. They're going to get the same information shared in their epic everywhere. That part's good. I think sonnet getting into smaller hospitals good. But I personally want to see the whole world moving much more aggressively towards interoperability. I think the ONC missed it originally. I think their idea that you could fix it after you allowed all these disparate EHR has to be built without it. Um, we've got a mess and I don't think sonnetq solves it, but I think it's, it's a nice additional solution for epic.

Bill Russell: 17:39 Yeah, this is, this is one of those areas that I, it's, it's being from the outside of care. It's a seven or eight years ago, the first conference I went to, uh, there was another, I guess there's 12 CIO sitting around the table and they asked us all, do our introductions, and then went around the table and whoever the first person was, they gave their name, their system, their revenue for whatever reason. And you know what Ehr they were on. And I thought, wow, that's interesting. Okay. So it got to me and I said, you know, here's my name, my system. And you know, both are impressive numbers, so the numbers are impressive. And then I said my Ehr and it was, it was like I said, I didn't really graduate from college. I, you know, I only got an associate's degree and I mean, you could see people look down their nose at me and I was like, oh, this is, this is fascinating.

Bill Russell: 18:28 There's sort of a culture around what Ehr you're on. Um, and uh, it sort of reminds me of the Os wars back in the day when people would take sides and say, you know, I'm going to us two guy or I'm a windows guy, or, or I'm a Novell guy. And, uh, it, it, it really doesn't help us at all to be honest with you, to be so passionate about the EHR. My, my experience that I've researched is pretty closely is that the net distinction between these Ehr is a, in terms of overall running a hospital and being efficient is not that distinct. In fact, we were a Meditech shop with 16 hospitals, $6 billion. And a it when people would say, well, you know, it's, it was, that's an awful system to run that kind of health system on. And I'll just tell you from a number standpoint, it's highly efficient.

Bill Russell: 19:17 Uh, it, it does lag in terms of the user experience, but overall, in terms of running the health system, it was effective. It had very good technology and modules. It didn't go down. It, it was a very stable system. And, uh, I find people get so passionate about this and uh, uh, it's a little off topic. Let's talk inner operability on this. So the interoperability, uh, I agree with you. I believe that epic leaves that the path to interoperability is if everyone gets on an epic platform, then we will get to a, a longitudinal patient record. And that's just never going to happen. And we don't want it to happen and we don't want it to happen for, I think the primary reason we don't want it to happen, it's because we saw the same thing in the Erp world. And when you get down to very few vendors and you get down to a certain market share for those vendors, uh, the innovation slows down and it's not because they don't have huge staff and huge budgets, the innovation slows down because they have to innovate in a way that they're taking into account their, their European clients and their Australian clients.

Bill Russell: 20:25 And their, you know, 55 different clients in the u s for large hospitals and their small hospitals. It just gets too complex to innovate. And so we actually slow down innovation. We slow down the market. So I'm not sure we ever want to get to a epic world domination anyway. So we should continue to at things like the sequoia project and, uh, the Karan Alliance and uh, and some of the other initiatives that are out there as really the, the, the start of this interoperability journey. I sort of rambled there for a little bit. I'm curious what, what your thoughts are, um, in terms of what's, what's next on this and what's next on interoperability?

DrDavid Bensema: 21:12 Well, the next on this is I think you're going to see Cerner and others work towards the comprehensive health record more and more. Um, so the large players are going to be doing that. I agree with your assessment about the need for the competition to create an innovation. You and I grew up with the big four and we both drive better vehicles now because there's competition from overseas and from all around. Uh, so the innovations there, um, I think the other thing on interoperability, I think the high tech, um, I hold some hope that that group is going to come to an understanding that interoperability is the must have and we have some legislation that's driving it. Um, I think, you know, the physician voice and, and you're going to get to that in a moment. The physician voice more and more demanding interoperability. We're wasting too much of our clinicians times positions APRN pas, nurses looking for information that audit just be there and it ought to be in a usable format when it gets there and not in a linear format. The horrible, CCDS that we saw, um, the last several years. It's gotta be better than that.

Bill Russell: 22:27 Yeah, I agree. And I am looking forward to jump into the next section talking about physician burnout. When I sat behind a physician at one point and just mirrored them for the day, I was shocked to find they were jumping in to all these essentially pdf files and they, you know, so they have 15 minutes with a patient and they're, think about it like you have this folder full of 25 PDFs and you're just rifling through them real quick. It's, it really is an impossible job, which gets to, you know, our role. So, uh, you know, in our tech talk leadership, we're going to talk a little bit about the role of it and physician burnout. Uh, the reason I, I just appreciate your physician background, I'm going to use it here. So the, the onc and CMS got an ear full on Ehr. This was a politico article and I'll just read, you know, own CNC EMS officials got an ear full for a daylong listening session at health and Human Services. On Thursday about reducing provider burden from health it speaker after speaker said physicians and nurses are on the edge of a nervous breakdown over the depressing hours they spend struggling with bad EHR workflows and government reporting requirements. So, you know, let me ask you this, let's start the current state. Where do you think we're at with regard to a physician burnout today and, and, and you know, what are you hearing out there?

DrDavid Bensema: 23:52 Yeah, I'm hearing a lot about it. Um, the last, uh, Ama annual meeting, I'm a delegate for the state of Kentucky to the Ama. The last meeting was dominated by a conversations regarding physician burnout. It continued at the November interim meeting of the Ama. Uh, we, a year ago, year and a half ago almost now had the rand study with the Ama that showed, um, that physicians were spending two times as much time on the Ehr as they were with patients, um, that the burnout level was going up. That's physicians. Uh, career satisfaction was plummeting. We've seen some of this for years. I think, you know, from my experience, I came into practice in 1990 I think in 95, 97 when they came out with the ENM guidelines, uh, some of that coding documentation came from outside. It had nothing to do with how we really take care of patients or what was relevant to taking care of the patients.

DrDavid Bensema: 24:45 Physicians felt the pressure of that documentation got more and more copious and then you get Ehr is when you get note bloat and you'd get all the meaningless use, meaningful use requirements that tell us to tick some boxes that showed functionality of the Ehr in terms of it had this code, this capability, this field was able to be copulated, but it didn't do anything for the patient physician interaction and for the quality of care we were delivering patients. All of that builds up on the physicians. And so now we are seeing a critical mass. We're seeing that over 50% of physicians interviewed and surveyed are lamenting, um, that they're losing their satisfaction, their losing connectedness, a depression rates have gone up among physicians. They were high to begin with. I mean it's always been as stressful, difficult a role it needed compartmentalization. Now we don't have time to compartmentalize which we are racing from patient patient and still have the record waiting for us and then we go home and we feed the kids, tuck them in and spend another two and a half, three hours on the computer and you hear this over and over again.

DrDavid Bensema: 25:50 The thing that kind of amazes me about HHS and onc doing this listening session, you do these listening sessions when you really don't want to do it something or you're not ready or capable of doing something right because they have all this information. I just mentioned a year and a half ago we had it. I think that's one of the things that galls me about this. This was just like cation and delay. If they really want to get something done, get to work on interoperability, reduce some of the cumbersomeness. They are at least talking to us, HHS, and I think they mentioned it. They're talking about reducing some of the myths or requirements and easing some of that burden, but they've got to quit being in the physician and patient business as much as they are. Um, I have a very good friend, a doctor, Sean Jones, former president of the Kentucky Medical Association, just published a book finding heart in art.

DrDavid Bensema: 26:46 It's about his journey of burnout. I think it's an incredibly brave thing for him to do. He's a prominent ears, nose and throat physician in his community and prominent within the medical community at large. But it was a great gift on his part to other physicians. It's not every physicians journey, but the fact that he would take the time out of his life and his wife would allow him, she's also a physician would allow him to expose himself this way. It tells you how severe this is, how critical burnout for physicians is. And I think we as CIO's have an opportunity to help by really looking at the workflows and demanding of our vendors improve workflow.

Bill Russell: 27:25 Do. Do you think there is a, um, I mean, is there a risk in speaking out against some of these things? I mean, is there a risk right now of, of talking about a certain technology is, so if I were to sit here and say, you know, epic and Cerner have created way too many clicks and way too much, or if I sit here and say health and human services, I want to see Macra MIPS, these things have put way too many birds. Is there, is there a blowback that happens to people that are speaking out about these kinds of things or are we past that now where there's just so much of it going on that, um, it's just a matter of getting to the right, the right people to get the right things done?

DrDavid Bensema: 28:07 I think the risk is probably perceived to be there more by folks who don't have a clinical background. Those of us who have been practicing physicians, I think we're past worrying about the risk. We're desperate to find the right answer and we feel that for the sake of our patients and for access to care. Because when you burn out physicians, they resigned their positions, they leave the practice and access goes down. So if we're going to do that, I think we get over the fear. I think, and I know from conversations with the folks at epic, I haven't talked to the folks at the other large Ehrs um, but with conversations with folks at epic and I watch it Ugm and that some of the other conferences folks are getting in their face. Um, they're doing it in a civil way, which we always ought to do it in a civil way.

DrDavid Bensema: 28:55 People are being very forthright about what the problems are and they are starting to respond. And you're seeing some of that in the workflow changes, you're seeing some responsibilities, but I think they built to your point, these very cliquey systems that are incredibly complex, uh, coding and to go back and correct that and to streamline workflows is a big lift. And I think it's just getting a critical mass of all of us saying, okay, no more. We're not going to tolerate this any longer. You've got to do better. And then I think we'll start moving. They also know, you know, and I know that the barrier to change in it health, it is huge because of the cost is so high. That change tear and reimplementations I just went through. One, they're expensive and you do everything you can to not do it again. But I think if we're going to be good partners and I always talk about a good partnerships, um, our EHR providers and we as the users have got to have these hard conversations and be good partners and help each other to improve and get it right.

Bill Russell: 29:59 What is the, so we've talked a little bit about the, uh, the it side of it and the Emr providers. What needs to change on the, on the, on the regulatory side that, I mean we talked about the MIPS burdens coming down and maybe even some things have been uh, uh, east, but are there some other things we can look at to maybe roll back or some conversations we should be having that really drive for not just a listening session but that we as a health it leaders or maybe even a couple of the people at HIMSS that are listening to this or chime that they could advocate for on, on Capitol Hill and, and really move things forward.

DrDavid Bensema: 30:41 Yeah, I think HHS showed us a first step and eliminating the requirement for attending physicians in the academic centers to duplicate what's in a student note. They're starting to recognize that if it's in the record and it's available, it's in the record. It doesn't have to be duplicated. That's a great start. I think they need to look at the 95, 97 ENM coding guidelines and I know they are and say is everything that we're demanding necessary in the world of an Ehr where so much of that social history, you know, if I'm simply reviewing and moving on, I don't have to document it in every single note. Um, you can follow my clicks. Um, if you really wanted to audit me, it's auditable, uh, but quit making physicians be um, uh, scribes responsible for counting the number of boxes checked and trust them that when they say it's a nine, nine, two, one four visit, it is, and if you want to trust and verify, because I believe, you know, Reagan was right, trust and verify, um, then go ahead and look at the clicks. Periodically do some random audits, but don't make people put all this cumbersome stuff into the node. It's time consuming. It fills up page after page. If you do a printout, it's just honorus to go through it. I think we can have those conversations. We can make those steps. But this first step by HHS to eliminate the redundant documentation for medical students. Great. First step, there's a lot more steps to be taken.

Bill Russell: 32:14 Absolutely. And we talked about that last week with Charles Boicey on the show. Just how much data is in those each, our logs that you could actually just retroactively go through and create a lot of that instead of putting the burden on a physician. And that's just probably one of many cases. The only other thing I would have, we, you and I talked about augmetics last time, which was one of the ways to ease the burden. Um, I saw that UPMC yesterday. I saw, uh, uh, a post by a Rasu on what a UPMC is doing with Microsoft in terms of, uh, uh, having the machine do, the doc had to do the notes and record the notes while they're in the room. So that was a partnership with UPMC and Microsoft. So hopefully more things will happen in that area. But as is always the case with you and I, we could, we could talk for hours.

Bill Russell: 33:02 Uh, it's time to close the show. So a favorite social media posts the week. Uh, I'll kick us off. So, um, wow. I can't even read this. My eyes are getting, so I don't know what age that happens, but it's happened to me. So, um, this is, uh, titled how how you treat your loyal employees determines your future. Uh, Olag Fishin Polski, who I'm sure is an avid listener of the show. Um, but he posted a cartoon. I love these cartoons and it says, think twice before losing your best employee. And it has the, uh, has a, uh, like a plank out over the cliff and the employees, uh, walking the plank, except they're walking to land while the executive who's losing their best employee is sending out on the other end of the plank and about to fall into the abyss. And a, I think that's just a great reminder for us. So, uh, over to you, what's, what do you have for us?

DrDavid Bensema: 33:57 Yeah. Um, I didn't go for a social media post. I went for something that was ringing in my ears this week. And I'm a comment by my dear friend Steve Heck, I don't know that he originated it, but he was the original person that I heard it from. Um, execution trumps innovation. And the reason I'm bringing that up is a lot of our friends who are going to be at HIMSS and chime and particularly at HIMSS, there's lots of bright and shiny is out there. We have all these opportunities to innovate. First rule, execute, get it done right. I'd rather do old school, right. The new stuff wrong. And I think it pays off. You saw this in your work, uh, going to the cloud with your system. I saw it in the work of the team that I got to lead in the implementation of epic execution means everything.

Bill Russell: 34:41 Yeah. So will you be at Chime or be at Himss?

DrDavid Bensema: 34:44 I will not be able to. I had a family obligation not going to be able to make it out.

Bill Russell: 34:48 Yeah, it's a, well I'm going to, I'm going to drive over there and uh, look forward to catching up with some friends. So if you are a listener and you're going to be there, I would love to catch up with you. I'll be at the, uh, the chime event, the CIO forum on Monday, and then himss the rest of the week and stuff. Some time slots of people want to get together. I'd love to love to catch up. So thank you again, David for being on the show. That's all for now. Please. Uh, you can, um, follow, well actually I guess usually I say you can follow us. Do you have a Twitter handle? I don't know if you do. I do that. Oh, okay. Well, Let's just say they can follow you on your articles. You're writing for health system, cio.com and my articles over there as well. So a great publication. Love those, uh, of those guys for the service they provide. Uh, you can follow me @thepatientsCio on Twitter. Uh, don't forget to follow the show on Twitter @thisweekinhit and check out our new website thisweekinhealthit.com. And uh, don't forget, if you like the show, please take a few seconds and give us a review on iTunes or Google play. And don't forget to come back every Friday for more news commentary from industry influencers.