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March 10, 2020

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March 10, 2020: Healthcare needs a digital foundation. But what exactly does this mean, and how do we implement one? Is it a one-size-fits-all approach or is it necessary to take an organization-specific view to implement this key feature in digital healthcare. In today’s episode, Bill talks with Vik Nagjee of Sirius, Chris Logan of Scripps, and Clark Kegley of VMware, about creating digital foundations. The healthcare industry has always had a ‘sit back and wait’ attitude, the industry has often chosen to create applications and platforms themselves because of the sense that only they could understand the consumer. However, the tide is changing and shifts are happening at the top where healthcare is learning from other industries, like B2C and retail, about how to treat consumers. It is important to create a service-oriented approach and to leverage the strengths of other industries to best serve consumers. Vik walks us through what a digital foundation entails. He sheds light on the five features of a digital foundation which include infrastructure, consistent operations, experience, increased productivity, and intrinsic security. We learn that digital foundations are about agility, and being able to adapt to an ever-changing landscape. This evolution, however, will not happen overnight. Digital healthcare professionals face the dilemma of keeping the lights on while addressing innovation needs that move the needle forward, often within constrained budgets and resistance to change. We also discuss hypothetical use cases, where Chris and Clark present a picture of what solutions might look like, and Vik shares how he would advise a CIO wanting to implement some changes. This is an exciting conversation, and we look forward to seeing the changes continue to unfold. Be sure to tune in today!

Key Points From This Episode:

  • Find out about what’s happening on the frontlines in light of the coronavirus and COVID-19.
  • Digital foundation: What it is, why it’s important, and what’s happening in the space now.
  • The role that the clinician and the CISO play in the digital foundation.
  • Learn about what VMware is doing to cater to the consumerization of healthcare.
  • Insights into what healthcare systems will find doing a gap analysis and how to fill them.
  • Why Clark’s role entails him explaining the ‘what’ to partners about the digital foundations.
  • An overview of the five elements that make up the digital foundation.
  • Find out how foundational applications make it difficult for digital changes to happen quickly.
  • The dichotomy between innovation and continuing to run legacy applications.
  • Two important pieces organizations need to keep in mind when implementing new EMRs.
  • An empirical study: How the ideas of a new digital foundation would work in practice.
  • How application development would happen with VMware’s extensive stack.
  • The actionable steps Vik would give to a CIO who wants to lay a solid digital foundation.

Building a Digital Foundation – A Panel Discussion

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Building a Digital Foundation – Panel with Vik Nagjee, Chris Logan, and Clark Kegley

Episode 191: Transcript – March 10, 2020

This transcription is provided by artificial intelligence. We believe in technology but understand that even the smartest robots can sometimes get speech recognition wrong.

[0:00:04.7] BR: Welcome to this week health events, where we amplify great thinking with interviews from the floor. There is no floor this week, but that’s not going to stop us. Special thanks to our channel sponsors, Starbridge Advisors, Health Lyrics, Galen Healthcare, VMware, Pro Talent Advisors for choosing to invest in our show.

My name is Bill Russell, healthcare, CIO, coach and creator of This Week in Health IT, a set of podcasts, videos and collaboration events, dedicated to developing the next generation of health leaders. 

I was scheduled to host a series of roundtable discussions at HIMSS 2020. These guests were generous enough to find time in their recently completely vacated schedule to go ahead with this discussion. I’m really excited that we’re going to do this. The discussion is on a digital foundation for healthcare delivering outcomes as a service. Our panel is Vik Nagjee. We have Clark Kegley, Assistant VP of IS at Scripps in San Diego. And Chris Logan, Healthcare Strategy from VMware. 

Good afternoon, gentlemen. Welcome to the panel discussion.

[0:01:02.8] CK: Good afternoon, Bill.

[0:01:03.7] BR: Yeah, we were just talking in a panel discussion, we’re at least able to look at each other, so we will be testing out these new digital roundtable as we go. You guys have assured me that this is going to be real easy, because you guys have worked together before, so I’m looking forward to this.

All right, so this is a timely discussion. We’re going to talk about a digital foundation for healthcare. Really what a digital foundation for healthcare is about is about agility, it’s being able to adapt to a changing landscape, which if nothing else this week in this last month, we really do have a changing landscape in healthcare. 

Clark, let’s start with you. I mean, what’s going on on the frontlines right now in terms of just how you’re trying to adapt to the events as they’re starting to unfold? I think California has a state of an emergency in effect right now. How are things progressing on the frontlines?

[0:01:54.7] CK: Yeah. It’s a great question, Bill. I think it’s indicative of the industry challenges that we’re all going through. You think about the coronavirus and COVID-19 and Scripps being activated by both the county and the state to help along with other healthcare organizations, becomes a great exercise that you have every now and again, where you can really test your ability to respond to issues. Scripps, like most large healthcare organizations, they have good plans in place to deal with this stuff.

The part that I think is more so interesting around what we’re doing is what the industry challenges are presenting for all of us and part of the reason why you had a seat at the panel today. Yeah, I believe that our industry has long been the type of watch, wait and see perspective. Other industries, like finance and manufacturing and industries outside of healthcare, leveraging technologies from Apple and Google and Microsoft and others, for a very long time our industry was just watch that and see what happens. We can’t do that anymore.

So, I think what we’re doing in partnership with people like Chris and Vik and other organizations is we’re trying very hard to move to the forefront of being able to make changes. One big cultural difference that I would describe for healthcare organizations is in the past, our industry has always had a perspective of if we don’t create it, it can’t be right, because at the end of what we do as a human. 

While that’s certainly true, our outcomes are different, we can leverage the experience that other organizations have brought to bear in things like video conferencing, like we’re doing right now and those kinds of technologies that are desperately needed in healthcare.

Our perspective on it is we’re going to partner extensively with others and we’re going to learn from other industries. We’re going to leverage what they do well, versus trying to create it ourselves.

[0:03:39.0] BR: Fantastic. We’re going to do three things. We’re going to talk about what a digital foundation is, why a digital foundation is necessary and how it really helps us to in healthcare, to really adapt to the changing landscape.

We’re talking about coronavirus, but really, we are right in the midst of a significant changing landscape around the consumer and around just a new entrance into the market and a whole change in that landscape. We are going to come back to real life stories of how data and applications are being used to deliver new experiences on top of this digital foundation.

Vik, I’m going to go to you to talk a little bit about the digital foundation. Then I’m going to go to Chris and talk about VMware a little bit. Vik, set it up for us a little bit. Talk about the digital foundation. What is it and what are you seeing out there?

[0:04:30.4] VN: Yeah. Thanks for taking time again today, guys. Digital foundation, so before we start and go into the what, let’s talk a little bit about the why and why is this so relevant now. If you actually look at a lot of the leading healthcare organizations and Scripps is one of them too, you’re starting to see a shift at the top. The top is basically starting to say, just as Clark mentioned, we’re in the position of learning from other industries now.

We’re starting to embrace a lot of learnings from B2C, a lot of the retail businesses, what can they teach us? The fundamental thing that they teach us is like, look, we need to focus our attentions on the consumer. In healthcare, we really haven’t previously done a very good job in defining, we say patient, right? The patient is somebody that comes in and gets treated and then we get money for that and then off they go. Changing that into the consumer and starting to treat the patient and their family and all of the rest of our IT team and the rest of the providers in the organization as constituents and consumers of things that are needed to run their daily lives. I think that’s the big trust that we’re seeing here.

What that’s doing is that’s reframing what CIOs are really looking at, right? They’re now have the classic Gartner bimodal challenge. One is I got to keep my lights on. I got to keep things running the way that they are, without compromise; high-level of availability, high-level performance.

Then the second is I’ve got these folks coming in as to digital officers, as chief experienced officers that have come from retail and are saying, “Hey, we need new ways to engage our constituents and we need new ways to keep them engaged and we need good ways to keep them coming back for services to our organization,” so that’s the whole consumerization. 

Those require a net new type of applications and net new type of way of actually displaying your information and soliciting feedback and bringing them into the fold.

How does the CIO straddle both the providing of frameworks for keeping the lights on, as well as this net new way of consumerizing healthcare? That’s our premise of saying, you need a strong solid digital clinical, or digital foundation that allows you to do all of those things and keep moving forward.

[0:06:50.2] BR: Yeah. It’s also the clinician and the CISO so as well, isn’t it, Vik?

[0:06:54.1] VN: Yes. Absolutely. Yeah. The clinician is also if you look at the new generation clinicians coming in, they’re very used to having things their way, right? They’re very used to having access to information, when they need it, how they need it, where they need it. They’re also very finely attuned to the fact that the wealth of data and information that’s out there and the lump and the rate that that data and information is growing at, they don’t have a capacity to be able to get their arms around, similar to reading a few journals in the past and being able to make decent decisions. They want to make the best decisions with all of the data that they have available. That’s one.

Then the security piece is that’s just table stakes now. That’s Maslow. It’s got to be intrinsic to everything that you do. You can’t have it as a bolt-on. It’s no longer about, “Oh, my God. Look, we got to go secure perimeter over here and then we’ll be fine.” That’s not happening.

[0:07:48.0] BR: Chris, getting VMware, it’s interesting because you guys really ushered in a complete fundamental change of how we did internal IT, probably about a decade ago within healthcare and virtualized that whole environment and then layered all the things, put automation on top of it, secured it, now have virtualized storage and network and everything else. How are you guys going to play the next round of change around this digital foundation for the consumerization of healthcare?

[0:08:17.1] CL: Yeah. I think there’s an important point that Clark made earlier, is that we’ve always tried to do it on our own in healthcare, right? I have this experience having come from the other side of the desk and into the partner world is that we always tried to build it on our own, so we were always laggard.

We’re starting to see an industry shift and how they’re adopting technology to meet consumers’ demands and needs. I think that’s important. It’s an important aspect, because it’s not just about the clinicians that you’re serving anymore. It’s not just about the patients, also those consumers are changing as well. The expectation of keeping talent in-house, because people have expectations of technology that they’re using because we’ve consumerized technology so much. So, they want it a certain way, like Vik said earlier also. They have a certain expectation of how they’re going to do their jobs and their work.

I think from VMware perspective is that we’ve got the secret sauce. We’ve done some very slick things over the past few years. If you look at our history where we started, people still consider VMware just a virtualization company. Well, we do so much more than just virtualization in your data center. Now we’re extending that virtualization not only into storage and to networking, but also into security now, where security is inherent in the platform. It’s just ingrained into it. It’s intrinsic, so to speak, right?

We’re changing how people do their work, which is very critical because people have an expectation of how they’re going to do their work. What the consumer doesn’t care about is what it takes to get their application any more. They have the expectation of the applications just going to be presented to them in the form and fashion that they see fit and they’re going to have an experience time and time again, where VMware plays in that spaces, we’re making the lives of the IT departments, those providing this type of service as simple as humanly possible by giving them the opportunity to take advantage of consistency within the infrastructure. Whether that’s to compute the networking and the storage, and then changing how they’re operating.

No longer are you constrained or bound to the four walls of your data center, where you can now start to look at workloads and move those workloads where you see fit from an operational standpoint. Important point here when we start to talk about healthcare and healthcare delivery, Bill, as you know being that CIO from just a few years ago is that, are the applications ready for that movement in this world?

We’re looking at it from the lens of how can we not only change the infrastructure which is providing that service, but how are we now addressing the application in that portfolio so you have that seamless experience, while securing that entire ecosystem in one fell swoop? It’s definitely not an easy task, but it’s a task that we’re definitely up to because we value how the providers are using technology.

We want to see better outcomes to those patients that are being seen in the clinics, or wherever they want to be seen and we want to use technology as a differentiator to take away the bounds for how healthcare is being delivered. VMware is going to play a very critical important role in that, because we see care not just at the bedside anymore, but care has got to be a part of everybody’s lives on a day-to-day basis as we’re taking care of populations.

[0:11:17.4] BR: Yeah, I like to come back to this word ‘agility’. Clark, I’m going to come back to you. It’s interesting to me, at one point my team was talking about how they automated all this stuff on top of our infrastructure internally and this is back in the old days. I said, you know what would be really interesting is if I could say, “Hey, Alexa. Provision me some servers and those things.” That was a Friday. On Monday, I came back in, they said, “Okay, we’re ready to demo.” I’m like, “Demo what?” Like, “We’re ready to demo you talking to Alexa and it provisioning for servers, or whatever you want it to provision.”

I was sitting there going, “I have so few projects in healthcare happened that quickly, that I was taken aback.” That’s really what we’re talking about. When the new entrant comes into your market, when CVS, or the Walgreens comes in and starts offering services different, or Amazon Care or whatever, or coronavirus hits and all of a sudden, now you need to be doing massive telehealth that you weren’t able to do before, you’re going to have to be able to spin up things that you weren’t doing before.

Clark, give us an idea of how you – most of these things start with a gap analysis and most – help us to understand some health systems are going to be starting really at the ground floor and some are going to be pretty advanced. What are they going to find when they do the gap analysis? What are the most important things they need to put in place?

[0:12:35.8] CK: We’re doing this video conference, Bill. It’s a great statement and a great set of questions you make. We’re doing this video conference, because one of the biggest healthcare IT shows in the country, if not the world, HIMSS National got cancelled this week, right? One of the benefits of going to conferences like that for me is we get a chance to connect with colleagues and other health systems around the country. We all discover that many of us are experiencing the same kinds of challenges. There are other health systems that will be a little bit ahead in some areas. And in other areas, Scripps may be ahead.

I think it’s indicative of the real culture shift that has to happen. Vik, I think touched on it. It starts at the top. But it must really, really disseminate down into the depths of the people that do this work. Part of my job is articulating technology for people that really don’t want to hear about technology, don’t care about technology and don’t need to know about technology. I was at one of our hospitals recently and demoing our enterprise architecture strategic plan, which is a graphic that we’ve done in one sheet, one side only, which is one way to explain the what, not the how, that’s part of the culture shift that healthcare organizations need to go through. A group of managers asked me. They said, “Clark, what’s your vision? What is your vision for enterprise architecture at Scripps today?”

Again, back to that perspective of culture change and how you get folks in that space to understand it, so what I did is I held up my – this is my smart phone and I said, “In every aspect of your life, you can learn your life from this, but your healthcare. We intend to change that.” We’re not there yet, but we’re well on our way. I think it is that notion of blow up what we have traditionally done in healthcare and then apply principles, like speed-to-market, which are very foreign in a lot of healthcare organizations.

Agility, certainly many of us adopt agile principles, but have we really embraced and endorsed and reinforced from the very top that we must deliver goods and services based on the needs of our customers, not based on the needs of us? Which causes us to go much faster than we have. Then again as we approach that, really smart people in healthcare IT approach that, don’t feel the need to try and create everything yourself. We talked about that earlier, right? There are lots of great companies that are willing to partner with us, to help us learn from that.

If you don’t have that down to the absolute frontline level, so that everybody understands where we’re trying to go, you’re going to fail. It’ll be the initiative of the week that too often plagues healthcare as an industry. To get by that and Vik knows, as Chris knows this, because it’s actually over my shoulder right here partially; my laminated strap plan that we walk around and I can tell that story in about three minutes to anybody that is willing to listen and those that aren’t willing to listen sometimes. But everybody understands what it is we’re trying to accomplish and why.

Now what’s interesting about it, Bill, is as you think about the real creativity that exists in healthcare IT shops today, part of my job is to explain via partners what. The collaborative nature is to let turn the team loose on the how. That’s actually really energizing and it’s a lot of fun to watch. Certainly, our teams here at Scripps just get super creative and go after it.

[0:15:47.3] BR: All right, so here’s what we’re going to do. Vik, I’m going to ask you to talk about the digital foundation, some of the elements of the digital foundation, then we’re going to get really pragmatic and I’m going to come back to you guys. 

Here’s the example I’m going to give you, today, 21st Century Cures, final rule goes into place, which means that essentially, what the OMC is pushing towards is that the data becomes an asset that is used for health. No health system can really control the data anymore. No EHR provider can control the data anymore. It has to be freely accessible to the patient in order to manage their care and in order to provide the best care possible.

All of a sudden, we’ve taken this data and we freed this data. This is a seminal event within healthcare. Now we have all these data that’s going to be not only our data from the provider side, but also from the payer side also has to be made available as part of 21st century cures. We’ve just created this new ecosystem that is going to really put a lot of data at play and a lot of really smart people are going to come up with solutions and say, “Hey, you know what we can do now, now that we have the complete longitudinal record and now that we have this, we’re going to be able to do some things.”

We’re going to from a pragmatic standpoint, I’m going to ask all three of you to talk about what solutions and really the ‘how’. How would we go from where we’re at today, to launching some new solutions? First, I want to go to Vik. Talk about the digital foundation. What are some of the elements of a digital foundation?

[0:17:14.2] VN: Sure. Sounds like you’ve been busy today reading the 1,700 some pages that came out. That’s okay.

[0:17:20.0] BR: I read the bullet points. Go ahead.

[0:17:21.3] VN: Yeah, I was doing that too all day. But no, I’m just kidding. Fundamentally, I think there’s some amount of agreement on some of these different categories that I’m going to mention. I’m sure there’s folks – Chris might want to add some. Clark might want to add some.

I think fundamentally, there’s five different areas that I can say there when I’m thinking about a digital foundation. I put clinical in parentheses, because we’re talking about this in the healthcare space. I think it’s true of any digital foundation. There’s five and Chris, some of these will sound familiar to you. One is around infrastructure. So, consistent infrastructure. I’ll talk a little bit about each of these and then we can dive into your questions.

You got to make sure that in order to do this bimodal thing that we talked about, we’re going to keep the lights on, we’re going to make sure that your services are running no matter what, unquestioned, high-performance, high-availability and that you have the freedom and flexibility to be able to grow and shrink as needed, to be elastic as needed. I think you need to have that level of consistency in your operations, but then also in terms of your infrastructure very specifically. It just needs to work, just needs to be there, you need to be able to rinse and repeat, grow as you need, etc. That’s the first piece.

Second pillar is around operations and I touched on this previously. Again, consistent operations. Consistency in terms of being able to say, “I’m going to start embracing the future world of service-based delivery.” I have the service catalog and I have the ability to be able to go through and provide these services. Now we’re very far away from being able to do that, but just conceptually, those are the kinds of things that we could probably take and apply to have a really good, solid digital foundation. That was the second piece, consistent operations.

The third one that I like to add and I like to think about here is around experience. If you actually say, one of the pillars of my digital foundation is consistent experience, then you can peel apart and say, “Okay, who are my constituents? Who am I trying to provide these experiences to? Is it just my patients? Is it my patients and their families? Is it my patients’ families and caregivers? Is it all of you above, plus the IT staff? Is it all of the above, plus the executive staff of the organization? Is it all of that, plus the community members?”

The answer really is is that it somewhat depends, but I think that the right answer is everybody. The whole shooting match, right? This will come back to the ruling that you mentioned here in just a second.

Then the last one two elements and Chris talks about this a little bit before and I’ve been thinking quite a bit about this and Chris might want to touch on this a little bit more is this whole concept around productivity. A core tenant of the digital foundation ought to be increased productivity. The increased productivity is for your staff, but then also for folks that are trying to use the services that you’re trying to provide them as an IT organization.

It’s not only onboarding, so somebody comes on, you’re able to get them off to the races very quickly, but it’s also about taking the friction out of everything you’re doing on a daily basis; productivity. Just think about all the millions and millions of dollars that companies like Microsoft has spent in terms of recasting very slowly over time, reshaping what the overall operating system experiences for the user, but then also for the provisioner of those services. Windows 10 is completely off to this – the beaten path, if you will, of original operating systems. That’s the fourth piece.

Then the last piece, which again is like Maslow. You got to have it. It’s intrinsic security. You can’t have a digital foundation and both on security. I said that previously. I’m going to repeat that again. It’s got to be built in at all of the layers. One of the things that I mentioned here that ties this together, this is not really new stuff. This is stuff that we all been saying for a long time. I think what’s new is that we are starting to see that there’s not much runway left before we all have to start moving the direction of adopting, because I think that’s the differentiator.

There’s drivers for that, right? Why would you change your behaviors? You change their behaviors if there’s either a characteristic, or in some cases, both. In this particular case, you have the situation where you have these digital enthusiasts coming in, all of these folks that are consumer first, coming in from B2C. You’ve got all of these next-generation providers coming in that are like, “Look, I need access to a vast majority of data and information to make the best decisions possible and there’s no way that I’m going to be able to keep up with all this stuff.”

Then you have the consumers that are like, “I just want to treat this like my Starbucks app, or my Target app, or whatever it is.” It doesn’t matter what it is. That’s one carrot and stick, if you will.

I think the other one is as you mentioned previously, Bill, right now is very timely. There’s two things that are being talked about quite a bit. Telehealth and remote work. These are the two things that a lot of organizations are talking about right now.

What do those need? Well, they need a lot of stuff. Fundamentally, they need a framework and a platform that you can actually expand and contract when you need. This is elastic, right? You grow when you need, your shrink when you go. Very different from what we’ve done in the past.

The last item I’ll mention is that the reason why it’s so hard to embrace this, even if we conceptually and academically say, “Yes, we understand. This is a digital platform or foundation and we’ve talked about it for a long time. Now we have a carrot and a stick. Why aren’t we doing something very rapidly around this?” 

Because it’s really hard to do. It’s really, really hard to do, because we have these applications that are foundational, they used to called legacy. Cannot call them legacy anymore. Call them foundational. Foundational applications that keep us very grounded, that require us to have a certain amount of doing things a certain way, some specific platforms, some specific delivery mechanisms. That’s a very big portion of keep the lights on bay to operational consistency.

That’s why I see that there’s this dichotomy that exists today around digital foundation thing and how do we actually operationalize it and make it real? I’ll pause there and then hand it off back to you, Bill, and then we can take it from there.

[0:23:25.7] BR: Yeah. You’ve given us a lot to talk about. Chris, I really don’t want to frame this, because if there’s stuff you want to add to that, I want to hear it. But one of the things I do want to push on is just ask you – When I talk to CIOs today, there’s a lot of them that are still struggling with that 95% of their investment every year is still going towards the old, keeping it running and maintaining the old environment. Is that changing? Because if you’re still spending 95% on the old, you don’t have the money to invest in getting the digital foundation right. Is that changing? What things are we seeing to change that?

[0:24:00.3] CL: I see a blend as I have conversations across the country with a lot of different CIOs and a lot of folks that run technology shops. It’s definitely a blend. I think it’s a cultural phenomenon that people are still want to hold on to the past and they want to hold on to that application that they’ve had for so long. If you look at on the flip side of the other side of the coin, the flip side is that nobody has the money from a healthcare perspective to go out and reinvest in brand-new technologies, right? The reimbursement rates there, they’re not what they thought they were going to be. You don’t have deep pockets anymore. You’re looking at shared risks through the care continuum.

There’s a lot of other business drivers that are causing folks to continue to keep up with I’ll say legacy, because it is legacy. That legacy technologies, those applications and infrastrutures, because they do their job. It’s really tough to pry that application away from somebody, when it does its job and it’s actually bringing money back into the organization. It’s a mixed bag, where some folks are definitely well ahead of the curve and they want to use innovation to really drive how they’re changing the dynamics and the shifting dynamics of patient care. Then other folks just can’t afford the innovation, because we’re stuck in that rut of keeping those lights on.

We try to always encourage folks to have a blended approach to it, right? You’re not going to change exactly what you’re doing overnight. This is going to take time. You can’t drink from the fire hose when it comes to dealing with a new digital foundation. One, because you may not have the skill sets necessary to do that. I always lean on people and process first, before technology. Technology’s great, but if I don’t have those other two foundational elements in place, technology does absolutely nothing for me.

Changing overnight is not going to happen. It’s going to be a slower draw across this period of time, as we look at how innovation is creeping into organizations. I think where the rubber is starting to meet the road and I think where Clark hit the nail on the head perfectly is that it’s coming down from the top now, because they see how important the change in consumer dynamic is in healthcare and how technology’s really going to drive that.

We’re having a much, much more deeper conversation about how we take organizations from where they were 10 years ago, to start to think about 10 years in the future? And laying out roadmaps for them. I think that’s where Vik’s definition in how we laid out those five key points of a digital foundation are very spot-on, right?

Now, I could get into the blocking and tackling of each of those, but I don’t want to because I think from the theoretical lens that he put at it, it’s all those pieces that are necessary to start to move an organization forward. What I would save the people is that you don’t have to do all of them together. You can take a balanced approach to getting to that point, which will in time free up that capital, so you’re not working on just keeping the lights on, but you’re also addressing some of those innovation needs within your and moving the needle forward for your organization.

[0:26:53.3] BR: Absolutely. Clark, one of the things – we call it the A word on the show and that’s Architecture. The reason I call it the A word is because when I throw it out, people sometimes gloss over. They’re like, “Ah, he’s talking about architecture again.” But I found it to be a fundamental part of the conversation, when I’m sitting there and people are saying, “Hey, you need to reduce your costs.” I go, “Okay. I’m going to reduce my costs and let me tell you how we do it in IT. We standardize, we consolidate.” What does that mean? Well, it means we can’t have this many cardiology pack systems and we can’t have this many radiology pack systems and we can’t have this many –

Now we focused in on the EHR. For some reason, that conversation has gone real well and a lot of people have gotten to a single EHR, or moving towards a single EHR. It doesn’t seem to have permeated the entire organization. I’m not sure how we move the needle forward without addressing the stuff that’s in our closet.

[0:27:50.7] CK: It’s a great comment that you make, Bill. I think the thing that we have to keep in mind, particularly around the EMR conversation is the easy part in many respects is going to a new EMR and getting it implemented. Beyond the implementation piece, you’ve got two or three things that an organization really needs to think about.

Certainly, one is that workflow dynamic that you have in your acute and ambulatory spaces. How many organizations go to a new EMR, try and pigeonhole that EMR into the old workflows that they used before they got the EMR? That is not a good approach. Organizations have to be really forward-thinking about taking all the capabilities of that EMR in really looking at each individual workflow and saying, “How am I going to do things differently, leveraging the tools that I’ve got in my shiny new EMR to drive positive patient outcomes to be more efficient?” All those things, we all talked about. That’s number one.

Number two is that application rationalization conversation that happens after you implement the EMR. Most large healthcare organizations approach it the same way. We say as part of our justification for getting the budget to be able to implement a new EMR, no matter who you buy it from. I’m going to be able to get rid of this percentage of applications. They’re going to go away, because I’m going to have a consolidated set of functionality capabilities that are going to replace those applications.

I do agree with Chris. The word ‘legacy’ still exists in healthcare. What happens beyond that? I’ll give you an example at Scripps. We had a portfolio of about 1,100 apps all in before going to our brand spanking new EMR. There’s still a list of applications somewhere in the low 800s that we’re now jumping into and saying okay, there’s two criteria around that. Does the current EMR have that capability today? If it does, there’s not a strong argument for keeping that application here.

Then the second one, if we’re willing to be honest and look internally, look at our own application stack, do we already own three of these? Do we own four of these? If you own several and that the functionality is not your EMR, you still have an opportunity there to reduce and to save some costs. Then once you begin to do those very painful set of discussions, there’s maintenance costs for the hardware. There’s hardware you probably don’t need any more, there’s space in a data center you may not need anymore. All of those things get rolled together to tell the story about how you can further reduce. I would say not in a simplistic way. Getting the EMR in is the easy part. It’s all the stuff afterwards that gets really, really hard.

[0:30:27.7] BR: All right, guys. Rubber meets the road. I’m going to give you an application. I’m a physician in a health system that you’re working with. I come in and go, “Okay, guys. Here’s how this is going to play out.” By the way, I do believe this is a real application. 21st Century Cures frees all this data. Here’s what I want our health system to do; I want us to create a service where people are able to aggregate their entire health record, they are able to have Scripps, or fill-in-the-blank client and essentially, they’re going to send us their entire medical record, including their Fitbit data and their Apple data and all that stuff. We are going to actually use our clinical expertise. We’re going to have a call center and a digital foundation for this. We’re going to use our expertise. We’re going to scan these records, look for any anomalies and we’re going to provide either a report back, or tele – not a televisit, but a conference call like this to have a conversation with the person about their health and those things.

We’re not necessarily going to do telehealth across, because they’re still state guidelines and those things, but we’re going to provide this consultation for people around their medical record, or a second opinion thing, and we’re going to stand this up as a result of 21st Century Cures. All right, we’re talking about this digital foundation. How are we going to make this happen? Who wants to go first?

[0:31:47.0] CK: I’d love to go first as an old integration guy, Bill. Because I have some strong opinions about this. First of all, in our industry we produce a whole lot of data. That is not news to anybody on this call, or anybody in our industry. I think the sweet spot for us is data with context is information. We need to produce way more information than we do. In the use cases and the consumers of that information are very different than they were even a few years ago. We would all certainly identify providers, executives, others working in the clinical process that they need specific data that helps them understand.

If you think about aggregating all the data, Bill, to your earlier points, that is a very good thing for patients and for those to take care of patients, then creating the right context depending on who you are. An executive may say, “I want to know what it costs to do a particular procedure on an annual basis and drill down into that and see if we’re actually competitive in the market or not.” Individuals going to want to see all the things relative to their specific ailments, any chronic diseases, those kinds of things.

An ACO is going to want to see much broader data, trended data across a population and so on. If you can’t quickly get to a point where you can provide the right context for the consumer of that data, then all you’re doing is producing to Vik’s earlier point, a massive amount of structured and unstructured data that no one individual could possibly consume and make clinical decisions with.

[0:33:19.4] BR: Hey, Chris. I’m going to put you on the spot and I’m going to take off the handcuffs here, because I know you’re trying not to talk about VMware. You guys have a pretty extensive stack. If I wanted to develop application and roll this out and scale this, talk to us about how we would do this on the VMware stack.

[0:33:35.6] CL: Yeah, sure. Of course, I can do that.

[0:33:39.1] BR: You guys don’t tend to talk about yourselves. I have to pull it out of you.

[0:33:42.5] CL: Yeah. I think it starts again, if you look at the foundation for the digital aspects and what we can do in this new world of a multi-cloud environment. What I mean when I say this, how can I extend workloads into a public cloud provider? How do I take attendance of what I need within my own data center to extend those workloads to take advantage of the microservices that are on the backend? That’s one aspect of it, because you can’t be expected to do everything in your house at a 100%. It’s just not capability, not a possibility.

Now if I want to develop the best-in-class applications, I’m going to find what I do best as a system. I’m going to go back to what Clark was saying earlier. Again, I’m not going to try to boil the ocean, but we’re going to find out what we do best. That’s the data points that we’re concerned with. That’s the data that we’re going to take in to provide the best clinical outcome to a patient, market that service.

Now I can create those applications using a whole bevy of theories about how applications are created. I’m going to try to stand them up in a containerized environment though, so I can have agility with how that application moves. Then what other services I can take advantage of within that application?

Now from a VMware perspective, the simplification of actually creating those applications in those containers and manage them alongside of your other infrastructure, that’s our sweet spot. That’s what we’re doing today. That’s what the future beholds for us. Being able to manage with consistent operations, making it reliable, extensible, scalable and having that agility in place to manage that environment seamlessly through one pane of glass, that’s the dream. That’s where we want organizations to get you to show that it’s not complex to manage the technology through that single pane of glass, and give them the flexibility and extensibility and scalability to be able to move business lines and services to meet that consumer demand. Because nobody’s going to build an application to do a whole bunch of stuff if it doesn’t solve the consumer’s demand.

Being able to scale that out beyond the walls of your hospital, into a multi-cloud environment, one, for cost measures, but two, just for simplifying your operations and extending out your workforce as we’re competing for talent. What’s most important in that regard is that ensuring that you have those other core tenets around that workload as it’s moving, so that intrinsic security, so that it follows the workload, so that you’re ensuring that you’re protecting that data, or that patients privacy and ensuring that in that consent model as they’re giving you their data, they feel comfortable with the fact that you’re in control that data, had all given point of time you’re preventing me from breaching, or minimizing the impact of that breach.

Two, bringing it back down to the endpoint to make it much more usable, so that’s that end-user’s story and component, right? Because the last thing we want to do is force feed a whole bevy of data onto a clinician trying to make a decision. At the same time, we have to have the patient engaged with their care, right? They have to want to care about it. Ensuring that we’re creating those applications, one, that are usable not just for the clinicians, but also for that patient as they’re providing that data back in and that it is being consumed in a normalized manner.

So, where are we coming to play there? Again, it’s that building that foundation of managing that IT environment, giving you the tools necessary to build those applications as you see fit in a containerized world, managing it all through a single pane of glass while taking into consideration the core tenets of automation, orchestration, operations and eventually, hopefully service requests and ticketing on top of all of that to drive how agile and digital foundations can be consumed across that continuum of care.

[0:37:07.0] BR: I love that, by the way. I mean, the multi-cloud – I mean, designing the application, so you can run across any cloud, I think is going to be critical. I think when you select a specific stack, you could get locked in, containerized, being able to move it. If you’re going to scale nationally, you need to be able to do that.

Vik, guess what? I’m going to give you the last word, but I’m going to change the question on you, which is you’re coming in to consult with me, CIO. I’m telling you, “Hey, digital foundation. I listened to the podcast. I get it. I understand I need to be more agile. I need layers of abstraction into the cloud. I need more security around everything that we’re doing.” Help me to get from here to there. What are you going to do for me? What’s step one through five in the process?

[0:37:51.6] VN: Yeah, way to put me on the spot right there. Thanks. Then also, you’re taking away to the big A. You bring up the A word, which is my thing that I’ve built my whole career on and switching on me at the last second. That’s fine. Thanks for that question. I think that that’s a really important question and here’s why, right?

I get sick and tired of talking with CIOs, CTOs, etc. They’re so jaded by the fact that when they ask somebody to come in and say, “Hey, can you help me with X.” Whoever comes in best interest at heart, etc., says, “Okay, here’s how you get to the end spot. Here’s where you are and here’s where you get to the end spot. Good luck. See you later.” You can’t do that.

Chris mentioned this earlier, is the beauty of digital foundation, if you actually structure it correctly, it’s like you don’t have to invite all of it off at one shot. It’s you figure out and articulate. This is how I would figure out and articulate where you are in this organization, what is the most important thing for you right now, for whatever is most important to you right now.

For example, if you’re a Pfizer, or another very large healthcare organization that has just recently made big investments in figuring out how to consumerize by adapting and adopting B2C-like engagement methodologies, applications, gamification, etc., etc., well then, maybe your big focus right now is around saying, “How do I get to a platform and a foundation that allows me to embrace digital as quickly as possible?” When I say digital, I mean, mostly mobile type applications, accessing from any operating systems for Android, iOS.

I need to be able to manage them. Some of these devices are managed, some are not managed, so there’s that component associated with it. That’s one area that you take on. You take your business goals and desires to tie that back to this digital foundation and say, “Okay, which ones of these is the biggest hitter for you?” In some cases, it’s going to be more around the journey of the consistent infrastructure piece, I think extends out and Chris’s explanation was really, really good. I really enjoyed it. I’m not going to hear me say that much about Chris, but I did enjoy that one.

[0:39:57.4] BR: I’ve seen him hit a golf ball. It’s not pretty.

[0:40:00.1] VN: You haven’t seen me in a golf ball. It’s even less pretty than that. The consistent infrastructure, like changing your mind in terms of saying, “Okay, now I’m thinking about stuff outside of my four walls,” is the only way you’re going to get forward. That’s the only way you’re going to do it. This whole next generation free the data application, building something to make – to start getting some really, really good gold from them there hills, the only way to do it is to actually be able to adopt and adapt compute and microservices from places outside of your walls, completely absolutely 100% agree.

There’s a couple of steps before that as to why folks are really looking at leveraging services from places outside of their walls, right? One is and quite touched on this, right? The 1,000, 1,200 applications rationalizing down to 800, not further rationalizing out, there’s still some lifecycle associated with that. Then there’s two pieces. There’s the application and the software associate with the users that are consuming that, but then there’s the infrastructure that the damn thing has to run on.

You can actually break those two things apart and say, “Okay. While I figure out this rationalization piece and figure out what my users want, I can actually take and liberate out some of the actual infrastructure that the stuff runs on.” Again, expanding out to other areas.

Long story short, come in and have a conversation, sit down and say, “Okay, here’s what the foundation looks like. Here are the elements of it. What are your business priorities Mr. or Mrs. CIO? What are you focused on right now?” Then let’s pick the one or two areas and just dive deep into those, solve those back out, go to the next one. That’s how I will do it.

[0:41:39.7] BR: Absolutely. I appreciate that answer. One of the things I did as a CIO is I came in and talked – You talked experiences earlier and I just talk about outcomes. I said, “All right, I want to get to no more than two racks in every hospital.” 

They just looked at me like I was insane and I’m like, “I don’t think I am insane. I think you can get to two racks in every hospital and get out of the data center and the expensive floor space that we’re taking. I’m not going to tell you how. I’m just going to tell you I know it’s possible.” I knew it was possible with hyper convergence and things that were going on. I knew it was possible.

Then I would say things like, “All right, I want to be able to reduce our IT operating cost by 2% a year for the next five years, reduce it by 10%.” Of course, they it’s not possible. Then they’ve come back and go, “Oh, you know what, if we do this and we do this and we do this, we’re going to be able to do that.” I think the same thing holds true here on the digital foundation. It’s pushing the team to say, “We need to be able to scale up this rapidly, provide this level of service, provide these kinds of tools and let’s just open up the creativity of an organization like Scripps and see what we can’t do for our community, our local community, but also the whole state of California and even beyond to open up some new markets would be really fascinating.”

Anybody want the last word before I close out?

[0:42:58.7] CK: I would just say on your comments, Bill, those really hit home for us at Scripps. There needs to be a fanaticism around weeding out transactional work in automation, because no healthcare organization, no healthcare IT shop that I know is going to get a large number of FTEs added to their current staff. The only way they’re going to be able to create capacity is to actually create capacity. Those are two important steps to creating some capacity to release that creativity that you were just describing. It’s actually really, really fun to be part of and watch.

[0:43:32.7] BR: That’s it. Clark gets last word in the show. Gentlemen, thank you. This is a lot of fun. I hope we get to do this again. This space continues to move so rapidly. I think we could – we definitely will be talking about this for the next year and look forward to some really good use cases coming out of this. Thanks again for your time.

[0:43:51.6] CK: Thanks, Bill.

[0:43:52.5] CL: Thanks, Bill.

[0:43:53.0] BR: I really want to thank these three for joining me on the panel discussion. I think it’s such a great and timely topic and discussion. We want to thank our founding channel sponsors to make this content possible, Health Lyrics, Galen Healthcare, Starbridge Advisors, VMware and Pro Talent Advisors.

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