Why the Future of Health IT is Customer-Centric

Dr. Lee Milligan:
After a dozen or so patients, the psych nurse called out to me, “Lee, the results are back on psych number two. You need to see this.” Now when an experienced nurse tells you that you need to see a lab result, that’s never a good thing.
 
Chris Hemphill:
That’s from Dr. Lee Milligan recounting his time as an ER doc. We’ll dig into it more after the break. He’s since become the Chief Information Officer for Asante, a three-hospital health system serving Southern Oregon. On today’s episode, we’re looking at the relationship between health IT, the patients they serve, and how we engage and interact.
 
Chris Hemphill:
Consumer experiences, major disruptors, and AI tech are shaping healthcare for years to come. On Hello Healthcare, we dive deep on these issues with leaders who are driving change. I’m Chris Hemphill, VP of Applied AI at Actium Health. We hope that these stories will help you to create or demand better future in healthcare.
 
Chris Hemphill:
Hello Healthcare. To begin our exploration of IT and healthcare, let’s go back to Dr. Lee Milligan’s story. When we left, we had just heard an experienced nurse give some bad news about a patient’s lab results.
 
Dr. Lee Milligan:
I rapidly made my way to one of the many computer terminals set up in the emergency department. After typing my username and password, I quickly saw my patient list. Selecting Mary, I navigated to lab results.
 
Dr. Lee Milligan:
The majority of her labs looked to be within normal limits. The aspirin level came back as less than 10, which is normal, the Tylenol level, however, came back as pending. In the world of medicine, when a lab test comes back as a pending, this usually indicates that the lab value is so abnormal that the lab staff needed to rerun the tests.
 
Dr. Lee Milligan:
I sank a bit when I saw the word pending. My mind went back to every other test result that I had seen that resulted as pending. All of them spelled badness. My head redirected to my time with Mary. She already told me that she had consumed Tylenol in large quantities. My gut told me that she was not lying. Lab result or not, I needed to get the antidote on board as soon as I could.
 
Chris Hemphill:
In health tech, we fixate on EMR versions, interoperability, and data feeds so much that we lose sight of what we’re aiming at. The end game isn’t the install or a successful training. It’s stories like the one you just heard, enabling people to save lives.
 
Chris Hemphill:
In the show notes, you can find the full story. Dr. Lee filled it with the suspense and heartache of the moment. It’s more real than an episode of House, and you get to see some inspiration behind a career of enabling healthcare technology.
 
Chris Hemphill:
So how are healthcare leaders like Dr. Lee balancing patient needs, physician needs, and health system strategies. Let’s hear from him.
 
Dr. Lee Milligan:
I would say it’s a fantastic time to be at the intersection of healthcare and IT. It is so exciting where we’re at right now, between the advent of AI, the ubiquitous nature of EHRs, the 21st century Cures Act, which although it causes me heartburn, philosophically I’m fully supportive of. So many great things are happening right now in the industry. It’s almost a magical time to be in the industry right now.
 
Chris Hemphill:
At the time we’re recording this, he’s right. Many innovations are getting the spotlight for their impact on patient lives and experiences.
 
Dr. Lee Milligan:
I think at its core, the function of IT within a health system is really about achieving the strategic goals of the operational leadership. Historically, that was really around just supporting them in what they’re doing when we have a pre-EHR estate.
 
Dr. Lee Milligan:
But now that the EHR is nearly ubiquitous and technology is integrated into nearly everything we do operationally, with mobility and digital platforms and everything else we’re doing today, I think that IT has to be that partner with operations in order to accomplish the goal. So at the end of the day, it’s really about identifying the operational goals and then having IT put in place all the pieces so that operationally they can be achieved.
 
Chris Hemphill:
Dr. Lee mentioned operational goals, but what does that mean for the customers of a health system?
 
Dr. Lee Milligan:
The way I’d approach it is first I want to define customer. From an IT perspective, my customers include the patients, of course, but really they include the people using the technology within the system, because if I can enable them to use that technology effectively, then they can better care for the patient when it’s all said and done.
 
Dr. Lee Milligan:
I get asked frequently, doesn’t the patient come first? Yes, they do. But it’s more nuanced than that. If we treat the docs and the nurses and the advanced practice providers, and everybody else is using our technology really well, they’re better positioned to care for that patient moving forward.
 
Dr. Lee Milligan:
I can tell you, as somebody who used the technology years ago, I can tell you that when you’re frustrated with what you’re using, it is hard for that not to be translated to your experience with the patient. And so, for our team, what I keep telling them is focus on the customer to have their experience be great so the patient can have great care.
 
Chris Hemphill:
Great points. Maybe the term customer is more complex than the Merriam-Webster version, which is a buyer of a good or service. The customer isn’t just the patient. It’s everyone whose experience impacts the patient experience. That introduces many moving parts to enable great care and great experiences. How do we know we’re doing this well? Is there some kind of report card for great IT leadership?
 
Dr. Lee Milligan:
I think, in the old days, a CIO could get away with simply managing individual aliquots of technology within the organization, and manage a few people and making sure that the lights stay on and technology continues to roll forward without two unplanned down times.
 
Dr. Lee Milligan:
That worked for a while, but within the last 10 years, there’s been a huge revolution in what this role really means, in my opinion. There’ve been great examples, I think, within the industry of CIOs who’ve been able to leap above that old framework and be part of the conversation about where operationally the organization is headed.
 
Dr. Lee Milligan:
I personally feel that the CIO needs to be in all of the conversations around decisions about what we’re going to do operationally when they’re big decisions, whether that means acquisitions moving forward, whether that means pivoting as it relates to strategy, if there are large considerations around finance. All those things have a technical element to them. It’d be very easy to make mistakes as it relates to those topics.
 
Chris Hemphill:
So for IT to be effective requires a shift. It’s no longer enough to be in a task-driven world, stand up this system and make sure there’s no trouble with it. It requires getting customer focused and involved in the health system strategy. We often hear that strategic leaders need to better learn technology, but what about the idea of technology leaders learning strategy? What does that look like?
 
Dr. Lee Milligan:
For example, let’s say we’re going to acquire a new private practice or a new system, and operational folks get together. They meet with the CEO, maybe the chief operating officer. They meet with the outside entity, and they shake hands or bump elbows, whatever it takes nowadays. Well, that’s great. But what if what they agreed on doesn’t correspond to something else that’s been in the works for a year and a half?
 
Dr. Lee Milligan:
The example would be if you have some sort of big implementation about to happen and there’s a freeze between date A and date B. Well, if they’ve agreed that the go-live is right in the center of that, then we’ve got a problem.
 
Dr. Lee Milligan:
That’s a small example, but those are the kinds of examples that I think without the CIO as part of the conversation, the operating folks really can get in trouble very quickly.
 
Chris Hemphill:
Dr. Lee really highlighted the shortcomings for strategy and customer experiences without IT leadership involved. I’m sensing a bit of yin and yang here, where parts of the organization have to complement each other in unexpected ways. This is especially true with new strategic approaches like AI.
 
Dr. Lee Milligan:
I will say that the recent past, or runway up till right now, has been not a straight path, and there’s been some disappointments. I remember looking at some of the AI technologies without naming names. There was one that was quite marketed, I’ll say, a few years back.
 
Dr. Lee Milligan:
I was disappointed in its actual capabilities. They were, in my opinion, getting out ahead of where the technology currently was. In the industry, we call that vaporware sometimes. But in reality, they were attempting to apply something, didn’t correspond to its capabilities. If you do that, you’re destined for disappointment. And so, I’ve seen that quite a bit.
 
Dr. Lee Milligan:
In terms of the CIO and working through some of these challenges and the AI piece, I would say it’s critically important that the CIO identify as one of the roles to be a translator. Now stop and think about this for a second. You’ve got a clinical team and an operational team, your CEO, your chief operating officer, your chief financial officer.
 
Dr. Lee Milligan:
These individuals, these men and women, did not arrive to their positions because they’re dumb. These are smart people. They figured out the cognitive pieces of it. They understand their domain very well. They’ve learned to navigate politics in order to be able to arrive at their position. Ultimately they’re very enabled folks.
 
Dr. Lee Milligan:
But when it comes to technology, I’ve noticed that frequently, the brain just get shut off around this stuff. It’s because it is a complex field and there’s a lot of nuance. It’s not part of their day-to-day stuff that they do.
 
Dr. Lee Milligan:
And so, I see part of the role of the CIO needs to be dedicated to taking all that complex stuff and distilling it down into a cohesive, digestible communication, because ultimately if they can understand the basic framework that we’re talking about, they can be your ally in making a good decision about where to go, because, again, these are smart people, but if they don’t have that basic framework in place, that the CIO hasn’t gone out of their way to really translate that information into something that they can understand, then they really can’t assist you in that process.
 
Dr. Lee Milligan:
So I spend a fair amount of my time thinking through how would I frame up all this stuff in a way where we can have a good conversation around this and I can benefit from their expertise, apply it to technology?
 
Chris Hemphill:
So that vision completes our yin and yang. How can we possibly know what 8,000 pieces of consumer tech and 20,000 pieces of health tech are actually relevant for our patients and our organizations? Effective IT leadership understands health system strategy and can clearly discuss the technology needed to enable it. Speaking of clearly discussing these technologies, Dr. Milligan had some useful thoughts on strategizing towards artificial intelligence.
 
Dr. Lee Milligan:
In order for AI to function, you have to have a couple of things in place. First, you have to have datasets. You have to have robust datasets that are representative of your patient population that you ultimately wish to take action on moving forward.
 
Dr. Lee Milligan:
Second, you have to have some level of data science expertise. I’ll tell you, it’s getting harder and harder, I would say, for community health systems to be able to leverage that. It’s infrequent that they have internal expertise to apply true data science to large datasets. Community health systems are going to have to learn to partner with other systems.
 
Dr. Lee Milligan:
Moving forward, there’s tons of applications for AI. I think it depends a little bit on how you define AI. In prior conversations, I know that some folks were referencing AI when they’re really talking about simple algorithms when it’s said and done. But AI is much more than that.
 
Chris Hemphill:
He shared some specific thoughts on managing population health. It all goes back to the patient.
 
Dr. Lee Milligan:
AI is really about the ability of the computational system to be aware of its environment, and then be able to take actions that further the goal, whatever that goal has been identified to be. And so, it’s really this whole idea of learning from what you’re doing and learning from what you’re doing and getting better and better at it.
 
Dr. Lee Milligan:
And so, in my mind, some of the overt applications of this certainly are population health. You’re on the hook for a year over year spend PM, PM. And so, how do you identify opportunities within that large cohort of patients where you can really dive in and identify where to spend your time?
 
Dr. Lee Milligan:
I also think about a lot of simple applications, everything from identifying what are the most likely patients or circumstances to result in a no-show? Pretty obvious one, but there’s a lot to be gained there, I think, from an organization, if you can identify simple aspects like that.
 
Dr. Lee Milligan:
Then, of course, there’s more advanced applications for it as well that have to do with research that’s super, super exciting. So when I think about some of the research that’s out there around some of the blood-borne cancers, and you think about lymphomas, et cetera, and the application of CAR T and where we’re going with that, large datasets, for the very first time, are going to allow us to be able to make huge progress in terms of who would benefit and who wouldn’t.
 
Chris Hemphill:
So we’ve talked more about it needing to understand strategies to be effective. We haven’t really spoken overall, though, on how to understand strategy to begin with. With all sides needing to learn to be more effective in this yin and yang cycle, what type of effort will it take for healthcare and technology leaders?
 
Dr. Lee Milligan:
Yeah, so I think it’s critically important that if you’re going to shift your career in a new direction, that you do an honest self-assessment that allows you to understand where your strengths and weaknesses are. What I found is that successfully doing that is pretty uncommon.
 
Dr. Lee Milligan:
I think part of it has to do with the … At least from a medical perspective, if you’re a physician and come at it from that angle, I’ve talked to a lot of my friends about my journey and about their different journeys who’ve done different things, and it’s rare that a physician is able to think through what do they not do well and really hone in on that and call that out. Then once you’ve identified that, then take action to do something about, because everybody who’s in the conversation has something to do really well and something they’re probably not very good at.
 
Dr. Lee Milligan:
So if you can identify that. And sometimes the best way to do that is to ask your closest associates, people who you’ve interacted with before and who’ll give you honest feedback.
 
Chris Hemphill:
Dr. Lee told us a story about this.
 
Dr. Lee Milligan:
I’ll give you one example for me. So when I moved into the CIO role almost two years now, two years ago now, I recognized that I hadn’t spent a lot of my time dedicated to security. Obviously that’s one of the big areas to focus on, and I really need to understand that.
 
Dr. Lee Milligan:
I felt a deep responsibility to the organization to make sure I understood it, that I could be confident that we have in place a system that can effectively thwart potential attacks. And so, I took that as a mandate that I need to understand this, reading, watching videos, talking to my security team, talking to outside experts.
 
Dr. Lee Milligan:
I was able to work with a guy named Bill Russell, who’s a friend of mine, to put together a virtual collaboration, I’ll say, with two other health systems around what we’re doing from a security perspective and what they’re doing. And so, it’s those kinds of things where if you can just honestly assess where you bring it and really where you don’t and then take some sort of action to get to a better spot, I think then you’ll be able to set a course where you want to go.
 
Dr. Lee Milligan:
I think that the risk, the big risk, is that you assume that you either know it better than you do or that it won’t become an issue for you moving forward. Those two assumptions, I think, are fraught with there.
 
Chris Hemphill:
To sum it all up, no matter where you are in the organization, being customer-focused means being dedicated to constantly learning. This means breaking outside of your comfort zone and diving into strategy or technology and expanding from there. Speaking of being obsessed with learning …
 
Dr. John Lee:
I was identified as the Dr. Nerd in our group.
 
Chris Hemphill:
That’s Dr. John Lee. Dr. John is SVP and Chief Medical Informatics Officer at the Allegheny Health Network. He also started out as a physician.
 
Dr. John Lee:
And so, when we implemented an electronic system in our ED, I was the natural choice to dive in. I probably dove in a little bit deeper than they thought I would dive, and I got really down deep in the weeds and helped with configuration and whatnot. So that gave me a very deep understanding of how these systems work or don’t work.
 
Chris Hemphill:
Why was Dr. John so obsessed with the ins and outs of their electronic system?
 
Dr. John Lee:
I remember being a young emergency physician back in ’99 when IOM’s To Err is Human report came out. Being a relatively fresh physician and being, I would say that, in retrospect, fairly typically overly arrogant, I thought the report was a bunch of hogwash. It was just a conspiracy to try to buttress trial lawyers in suing physicians.
 
Dr. John Lee:
But then fast forward, as I’ve done some of my administrative time and I started actually looking at some of the systematic things that occurred in our system once I got to my role as a CMIO, I realized, and then I actually went back and read the report, that the title’s very appropriate. They weren’t talking about bad doctors doing bad things. They were talking about good doctors and nurses and other healthcare workers doing what they could, but, unfortunately and inevitably, making mistakes because they are human.
 
Dr. John Lee:
That’s what, I think, led me to what is my obsession on how I approach my job now, is to really solve that equation where you have all this information out there, you have these people who need this information to deliver care or even be a patient, and there’s this gap in between that stuff is not flowing.
 
Chris Hemphill:
Dr. John had gone from data-doubter to data-obsessed. In that journey, he identified major gaps in how organizations would employ technologies. I’ve probably said it before on this podcast: the future is here, it’s just not evenly distributed. That quote’s from William Gibson, for all you Cyberpunk fans out there. Dr. John expanded on why addressing these gaps is so important.
 
Dr. John Lee:
So I would say that a meaningful use in the HITECH Act is a grand strategic example of the technical gap, where, theoretically, if you digitize stuff, then you make it that data and information were fluid and able to be delivered to the people who need it. But we all know that did not happen the way that we had fully intended.
 
Dr. John Lee:
On a more mundane level, an example that I often use is drug interactions, and particularly heparin and aspirin. Heparin causes bleeding. Aspirin causes bleeding. When you give them together, up pops an alert that says, “Hey, both of these drugs cause bleeding. Do you really want to give these together?” If I’m a cardiologist and I’m taking care of a heart attack patient, of course, I don’t want to see that alert. That synergy between those two medications is what I want.
 
Dr. John Lee:
So you have this technology and the information and the data saying, yes, these two medications, theoretically, do cause bleeding, but in certain situations you do not … Or actually in most situations, you do not want to actually fire that. But you want to be more nuanced about it rather than having it just be a binary fire or not fire decision.
 
Chris Hemphill:
Great point. In healthcare, where lives are at stake, all it takes is one exception for it not to be a clear binary decision.
 
Dr. John Lee:
And so, what you need to start doing is infusing things like has the patient’s hemoglobin gone down? What’s the patient’s platelet count? Are you a cardiologist? Is the patient a heart attack patient? Is the patient’s primary diagnosis a gastrointestinal bleed? Then you start infusing all sorts of additional data features into this, and it no longer is this binary on or off. It is an important interaction, but you have to consider all these other things.
 
Dr. John Lee:
Most systems now have not been able to incorporate that nuanced line of logic. When you start pulling all that stuff in, that ends up being data science.
 
Dr. John Lee:
That’s essentially what we’re talking about with artificial intelligence, so that the system knows that the patient is coming in with a heart attack, the person who’s ordering it as a cardiologist, I do not want to fire this alert to this provider because the other data surrounding this clinical situation warrants that even though this is a drug interaction, it’s not something that is appropriate to make somebody else aware about.
 
Dr. John Lee:
And so, then you multiply that out times, I don’t know, how many billions or billions of other similar sorts of decisions and data points that exist in all of our healthcare systems, that’s the problem that we’re trying to solve. That’s where the technology has to be bridged with how things actually work in the real world, the piece of it. I think ultimately data science and artificial intelligence is going to be the solution to that.
 
Chris Hemphill:
Okay. So I think I’m starting to understand. If we’re able to bridge the socio-technical gap, then we can start delivering the nuanced care that our patients deserve. Providing the nuance needed for a personalized approach is a perfect north star. However, that does beg a question: how do we get the data that enables this level of nuance?
 
Dr. John Lee:
I think there are two elements to that. I think just from a basic housekeeping perspective, you have to have a single place to house this. You have to have some sort of data warehouse. You can’t be looking in multiple places to find the data that you need to power these tools.
 
Dr. John Lee:
The second element, I think, is that the data that we have in healthcare is so unbelievably … There’s all sorts of crap in our healthcare data that really is not only irrelevant, but also leads to incorrect conclusions. A perfect example of that is something called the Glasgow Coma Scale and the SOFA score. The Glasgow Coma Scale is a measure of how alert you are as a person. That is one of the features that contributes to something called a SOFA score, which is a summation of how sick you are as a patient.
 
Dr. John Lee:
This came up relatively recently as we were going through some of the COVID crisis. As we were doing this calculation of the Glasgow Coma Scale feeding into the SOFA score, we realized that a lot of patients were getting Glasgow Coma Scales of three, which is the low score that you could get.
 
Dr. John Lee:
But that was because the patients were paralyzed and sedated because they were on a ventilator and is not a true reflection of the patient’s neurologic status. So there’s patients who’ve been on ventilators for any number of days or even weeks who have Glasgow Coma Scales of three, and that unnaturally suppresses the SOFA score.
 
Dr. John Lee:
So that dirtiness in the data exists all over the place. It also includes things like … A hot topic is having patient remote monitoring at home. But anybody who knows anything at the hospital knows that the heart rate on a monitor, even in a hospital, has all sorts of variables and artifact.
 
Dr. John Lee:
It’s entirely unreliable unless you fold that into some clinical relevance and an understanding of, as a nurse, I see the monitor going like this. That means it’s all artifact. Now if it goes like this, but the patient is comatose and they have a history of ventricular fibrillation, then this thing means that the patient’s about to die.
 
Dr. John Lee:
So that sort of understanding and clinical context that is missing in a lot of the data that we receive that would feed into these data science models. What you have to do is you have to actually clean the data so that when you’re calculating the SOFA score, you exclude all the Glasgow Coma Scales after the patient got sedated and paralyzed, or that you do some sort of pattern recognition and join that with if the heart rate is going like this and the patient is walking around, then, no, the patient is not in ventricular fibrillation.
 
Dr. John Lee:
It’s that sort are cleaning that needs to be done to make those sorts of data all that much more powerful for feeding into these engines and algorithms. The analogy that I’ve been using a lot is I think many of us have heard the adage now, data is the new oil.
 
Dr. John Lee:
So the problem is that we have really bad crude right now. Nobody would think of taking crude oil and dumping it in your car and expecting it to run. What we need is a refinery process. You take that crude oil, send it to the refinery, kerosene, jet fuel, all sorts of tar, and out another product is gasoline, which then gets shipped out. That is something that you can actually use in cars. That sort of process is what we need to do.
 
Chris Hemphill:
I’ll repeat that. Data is the new oil, but it takes refinement and processing to make it usable. If bridging this socio-technical gap and providing patients with nuanced care is the goal, how do we get there? Dr. John reflected on his transition into Allegheny Health Network and how he got started.
 
Dr. John Lee:
Well, I think what I’ve done is, in large part, the time that I’ve spent here so far has been just listening and hearing where are the gaps, at least heuristically from the perspective of the administration or the clinical end users.
 
Dr. John Lee:
Then people in our profession can help out is that we can take those gaps, those places where there are deficiencies, and think of technical solutions to bridge those gaps, so that if there is a problem with a particular clinical outcome, then think of some sort of decision support tool that is elegant, that people would actually use and understand that actually is helpful for them rather than just another popup that is bothering their workflow, which is a very common phenomenon.
 
Dr. John Lee:
I think one of the stories that came about from my previous organization is that we had this thing in our system called a preference list. It was built by an analyst when we went live. The very minute that we went live and I was watching a physician use it, I realized that it was built wrong. It was built incorrectly.
 
Dr. John Lee:
It was built technically correct, but there was all sorts of content in there that was missing. In particular, just even changing a display text for a physician for a particular order, I realized, was going to be tremendously helpful. So that day, I just rebuilt all the preference list on my own, because I knew what a physician would want to see.
 
Dr. John Lee:
It was laborious, but it wasn’t an overwhelming amount of work. That piece of engineering and build, it still exists to this day. The thing is that my colleagues, most of them don’t even know that I did that. That’s the way that these systems [inaudible] is how we should approach these systems, that the good stuff that is the good stuff should be completely transparent to the end user that it is something that’s good. It should be just there and it should match with how they think it and approach their workflow.
 
Chris Hemphill:
Let’s bridge between Dr. Lee Milligan and Dr. John Lee. Dr. Lee Milligan pointed that the customer isn’t just the patient. It’s everyone who influences the patient. With the story Dr. John just told, the importance of being customer-centric is abundantly clear. Those changes allowed physicians a better experience, and this results in better care for patients.
 
Chris Hemphill:
So far, though, we’ve been talking about how single systems impact the patient experience. Our care is much more complex than that. What happens when these systems need to work together?
 
Ann Goldman:
So it’s a lot, and just what we need, more acronyms.
 
Chris Hemphill:
You’re hearing from Ann Goldman. Ann is currently the Lead Digital Health Strategy Executive for Cerner, which is a major player in electronic medical records. When we were talking to her, she was at MultiCare, a health system in Washington focused on interoperability.
 
Ann Goldman:
So FHIR is just really HL7 over JSON. The FHIR resources in the past few years have become more sophisticated and more developed so that we actually can use them. So just to break out, because MultiCare, the organization that where I’m employed, we are part of CARIN Blue Button, but we’re also part of Da Vinci, and they are two separate things. Though they are very much interrelated in many ways and they both do have the backing of CMS and other parts of the federal government.
 
Ann Goldman:
So CARIN is more consumer-focused. That’s CARIN with a C, C-A-R-I-N. That is more about you as a consumer having access to your healthcare information, whether it’d be a payer or a provider.
 
Chris Hemphill:
Okay. So that is a lot of acronyms, but don’t be scared. Complex things are just collections of simple things. Solve them one at a time and eventually things start working out.
 
Ann Goldman:
I do believe we are finally going to be able to take advantage of all this investment, but that doesn’t mean that it’ll just happen for you as an organization. There’s still a significant amount of lift on the organization side, but there’s the couple things that have played into this. I think there’s been just early adopters have had success, just the normal kind of, I say, maturity curve of any technology. But also I believe that we have engaged leadership on it.
 
Ann Goldman:
But I think another factor here is the big technology players, the healthcare organizations, are also investing in this quite heavily and they very much want to see it succeed. And so, this gives you a jump start as an organization to be able to invest in this rather than building it yourself. That’s why I think we’re right to actually make this happen.
 
Chris Hemphill:
That’s great. But how do we actually know when we’re achieving success?
Ann Goldman:
 
This is where the government is way ahead of everyone else. So CMS has had great results with this and now is mandating it, or highly suggesting it now. We’ll mandate it later for everyone to follow suit. That is our early adopter.
 
Ann Goldman:
In terms of what is a measure here, the instantaneous nature of being able to exchange information through FHIR, that is the success in itself, how we’re able to respond to errors, whether with any of these use cases, gaps, and coverage. I’m going to name the three later on, but membership or even our med recon, which we’re currently in our auditing phase. The time save in the error reconciliation alone is a very good magic for success. Currently, we are in the med reconciliation post-discharge use case.
 
Chris Hemphill:
This is a great use case, by the way. Medical reconciliation means identifying all medications that a patient is taking, how often, and how much. It’s a process that can take up to 45 days. Remember those pains that Dr. John was discussing when certain drugs interact? Doing this quickly helps prevent that.
 
Ann Goldman:
It’s really quickly just going through the steps. First, you have, of course, the discharge. Then you have the discharge medication list. Then you need to exchange this medication list with the actual provider who is … When a provider, not the provider who perhaps did your surgery or who wrote your medication prescriptions in the hospital, but your provider that you do the 30-day follow up with.
 
Ann Goldman:
Then you need to also have these medications listed in the EMR for that 30-day follow up. Then there has to be the reconciliation and there has to be the attestation of that reconciliation. That attestation is the part that we’re auditing right now as part of Da Vinci, because the attestation is not necessarily charted. How do you drop that you’ve done the attestation in the provider office? That’s why we have had to actually augment FHIR with some work in Clarity, which is the Epic relational database, for those who might not know.
 
Chris Hemphill:
Again, don’t be scared of complexity. One step at a time.
 
Ann Goldman:
That is our first use case that we are underway. We started with Regents and with the med reconciliation post-discharge. So once you leave the hospital, you’re discharged from the hospital, the medicines that are prescribed to you and the medicines that you are taking when you have that follow-up visit with your primary care or your specialist in the office, that is a measure on a lot of value-based contracts.
 
Chris Hemphill:
To go from a process of up to 45 days to happening upon discharge, that’s a major move. How does this impact the patient?
 
Ann Goldman:
Particularly with our seniors, who … I’ve got to tell you, I worked in pharma a long time. And so, I am confused on my orders with medication when I’ve left the hospital. So I can only imagine for our [inaudible], how difficult this might be, as well as anybody else. Having that true [inaudible] on the medications, making sure you’re taking them correctly, there’s not any contraindications and so forth is very important. That’s why it’s a measure for value-based care.
 
Ann Goldman:
Getting this information from the payers to the provider on a timely basis within that 30 days has just been really challenging. It’s been a manual process in the past. So that is the piece that we have focused on first. It was one of the first use cases actually out of Da Vinci.
 
Ann Goldman:
So that is the use case that we are working on right now. How did we enable it? We have an API gateway. We are standing up our FHIR server actually through Azure. They have been wonderful partners with us, and FHIR as a service is something that they offer. You can either manage it yourself or have them manage it. We’re still going back and forth on that.
 
Ann Goldman:
So we are working not just to receive this data, but also push the data back to the payer as well to make sure that the attestation is done, not just with the Clarity file to say that we’ve attested but also the information through FHIR.
 
Chris Hemphill:
Remember when I said not to be scared of complex systems? The railroad blocks in healthcare when people are satisfied with the status quo. But the theme of this podcast is to create or demand a better future within healthcare. So how do you overcome the pushback when it comes to these types of efforts?
 
Ann Goldman:
I think the pushback is we have a process now that works, even though for all intents and purposes, it might as well be broken because of the time lag. If you’re so used to doing things and you just accept that time lag, that 45-day window, to receive information from the payer and what that means to a patient in terms of finding an actual per day per dollar ROI, if we actually invested in the technology, that’s really got us over the hump.
 
Ann Goldman:
We’re still just starting to see the benefit of that, but I’ll tell you we had a team of FTEs that just babysat and claimed files and waited for files from the payer. That team is now doing other things.
 
Ann Goldman:
So in terms of FTE hours for the ROI, we had a team of five people. So if you think about what that means for the organization, that technology has now replaced some of this man auditing that they have done, just sitting around waiting for files, calling to see why haven’t you sent the files, the files are wrong.
 
Ann Goldman:
That in itself is starting to prove out the measure we’ve had, which was the FTE hours spend on doing this work, as well as how much a misattribution was costing us in write-offs. For perhaps a member that acquired services that wasn’t attributed to us, we would write that down as an organization. Because they’re seeking care, that is the business we’re in, we are going to give them the care, but they attributed live to us.
 
Chris Hemphill:
So far, we’ve gotten deep perspectives on bridging the patient experience, patient care, and strategy all to health IT. As we just heard from Ann, learning your organization’s strategic language is especially important. While we’re focused on saving and improving lives, we often have to discuss in the context of investments and returns. Still, we like thinking beyond that.
 
Marc Probst:
I wish they could see the power of what we’re talking about. I wish that they fully understood this ubiquity of knowledge that could exist around the world and the lives that could be saved. I’m really passionate about how important data is in creating knowledge and how important that knowledge is for caring for people around the world.
 
Chris Hemphill:
That’s Marc Probst. Marc used to be chief information officer at Intermountain Healthcare. He’s now CIO at ELLKAY. As a health IT leader, Marc doesn’t just focus on specific health systems populations. He’s focused on the role that data plays in addressing global health issues. He shared his thoughts on this.
 
Marc Probst:
Wow. To try and prioritize that really is trying to get into the heads of people and what’s most important to them. To a diabetic, having good information about glucose levels and how they’re living their lives and the activity that they’re involved in, that’s the most important use of data. To somebody with heart disease, some of the data’s the same, their activity and those kind of things, but then there’s very specific data important to them.
 
Marc Probst:
I remember giving a talk where the statement I ultimately made, because I was focused in that particular discussion, around the standards and the value of standards in healthcare, and my point was there’s huge disparity around the world in providing healthcare.
 
Marc Probst:
There’s a lot of reasons for that disparity, but if we could standardize data and understand data, we could share knowledge. So if we can now have data that means the same thing in Kenya as it means in India, as it means in China, as it means in the United States, then the knowledge that’s starting to get created in each of these locations could be shared, because now it’s meaningful in each of those different areas.
 
Marc Probst:
The point I got to in that particular talk was that there are literally hundreds of billions, if not trillions, of dollars that could be saved and tens, if not hundreds, of millions of lives that could be saved if we could get to those standards and share that knowledge across the world. Then we could start to see some of those disparities go away, because it’s not necessarily the medical devices, although they’re important, but it’s really that knowledge that’s going to save the lives.
 
Marc Probst:
So it’s a long way around to your answer, Chris, but it’s really dependent on the individual and what’s most important to … Or population, I guess, and what’s most important to them.
 
Chris Hemphill:
Still, again, I’ve been repeating myself. Complex things are a series of smaller things. In this case, even though we’re thinking globally, we have to act locally. So where we work, how should we view leadership’s role in making healthcare work for our patients? Should this be entirely top-down?
 
Marc Probst:
Listen, leadership’s still important, and that doesn’t necessarily mean top-down. But leadership is still important. If you’re dealing in a clinical situation, you’re a clinician, you’re dealing in the hospital or in a clinic, it’s not that you don’t want to do these things. You’re just busy. And so, anything that’s new, even if it’s obviously good, it’s still difficult to change your workflow or change the activities that you’re doing.
 
Marc Probst:
So I do think there is a top visionary role to be played in what we’re trying to do with data and AI, and whatever it is, within healthcare. So I do think there is a top-down aspect of this.
 
Marc Probst:
What’s interesting, though, is if you get the visionary, if you get the leadership, and you start pushing these things, the people that are now seeing the benefits, they become very supportive. They become advocates for this. They become very excited about it. Then they can help go bottoms-up and really start to push new ideas, new things that can be done. I think at the beginning, it is, there is a leadership top-down responsibility there.
 
Chris Hemphill:
When it comes to addressing these broad issues, can there be a partnership between clinicians, IT, and marketing?
 
Marc Probst:
How good is that for the patient and how good is that for the health system? I’m not talking Intermountain, I’m talking about the industry itself or everyone involved with health. Just think, if we can … No, not if, as we become better at this, how many lives we can save and how much money we can save out of a very tax system?
 
Marc Probst:
But, yeah, when I started Intermountain and I saw Terry out there, I remember he was helping Homer Warner, I actually knew Homer. He died about six years ago, and it was really a sad day. But he was just as great as can be right up until the time that he died. But we had this clinical data, because that’s what Homer was, a physician, and that’s what you could collect at the time.
 
Marc Probst:
But like you said, marketing’s got access to all this metadata and social media data and all these other data sources that combine … And that’s where a lot of the proactive work can be done. We can see someone has a proclivity toward diabetes, but we can also then look at social media and see, wow, hope you enjoyed that Whopper and milkshake. Maybe we can do more of that.
 
Marc Probst:
But the whole idea of what we’re doing clinically and what we’re trying to do, I hate to use the term marketing, but that’s where the activity is, what we’re doing, the outreach and those kind of things, and where we’re bringing that data together. The power is just amazing.
 
Chris Hemphill:
It helps to know that there’s support from an outreach perspective. When it’s focused on getting people to make healthy to decisions, marketing actually isn’t a dirty word. What about getting buy-in from the clinical side of the house?
 
Marc Probst:
This is my experience, but in my experience, it was showing them the value of what we were doing, like advanced decision support. When we came out with decision support, it was this from the physicians. We don’t want that. It’s cookbook medicine. You’re telling me how to do my job.
 
Marc Probst:
We had to do two things. One was show them, no, we are just giving you some guidelines, some edges that we want you to stay within and it’ll help you. We had to prove that to them, that by staying within those guidelines, they were doing a better job. So we not only had to show them the data on how to improve their care, we had to show them that they were improving their care by using those tools and those guidelines.
 
Marc Probst:
So I think extending that to today to, okay, let us show you what we’re doing with this data and, together, how we’re working together to improve the care that the patients you have are getting. Clinicians are, one, quite competitive. And so, when they have data that they can see how they compare to their peers, that’s really helpful to them.
 
Marc Probst:
The other thing that they are is they truly care about their patients. Again, when you show them that the things that they’re doing, the things that we’re doing together with data is actually improving the lives of the people that they deal with, yeah, they come around pretty quickly.
 
Chris Hemphill:
Ultimately, what’s the corporate driver that’s going to enable data and care on this scale? Is it value-based care that’s going to push us in that direction, or is it competition to push us there because we don’t want to lose, or is it old fashioned fee-for-service revenue?
 
Marc Probst:
All three of the examples that you just outlined are financially based. Clearly, as the good sister said, no money, no mission. That still drives a lot of our thinking. So I think from a corporate perspective … And I’m not being judgmental here at all because I do believe in no money, no mission. If you can’t sustain the system, it’s going to fall apart.
 
Marc Probst:
Corporately, it is financial. I do think value-based care is the thing that’s incentivizing those corporate leaders to go that direction maybe quicker than they were. Fee-for-service was pretty … It was a different kind of mechanism. You made money just because of fee-for-service. Value-based care is putting new pressures on the system and saying, “No, we want you to save money.” By the way, if you save money, if you keep people healthier, you’re going to make more money. That’s a good thing, right? That’s incentivizing the system correctly.
 
Marc Probst:
So I think value-based care has a lot to do with it. If you’re a clinician, if you get out of the corporate suite, now they still care about money because of what I just outlined, but they also really are close to the patients and they want people to be better. And so, that’s the incentive there. But, yeah, what’s driving it I think is value-based care population health [inaudible].
 
Chris Hemphill:
Don’t lose focus. You might drift off to thinking about a software system that’s going awry, or why an outreach campaign’s numbers are off. These are important, but only in service of something greater. We shared these stories to show that even at the highest levels, there are people who remain focused on the patient through and through.
 
Chris Hemphill:
Lives depend on how fast information flows. Wellbeing depends on the quality of outreach and engagement that people have. It’s not about systems. It’s about enabling the right choices at people’s most critical moments. Don’t lose focus.
 
Chris Hemphill:
Thanks again for tuning into Hello Healthcare. If you like what you heard, we appreciate a review on Apple, Spotify, or wherever you’re listening. You and your feedback fuel us.
 
Chris Hemphill:
This conversation is brought to you by Actium Health. To get the latest on what these healthcare leaders are saying, subscribe to our newsletter on hellohealthcare.com or join us for our weekly sessions on LinkedIn. Thanks. When we see you next time, hello.